Annals of Family Medicine

Researchers Push Primary Care Teams to 'Power Up'

July 16, 2019 02:09 pm Sheri Porter

The team-based care model has long been encouraged by the AAFP, as evidenced by a policy first adopted by the 1996 Congress of Delegates and strengthened by the 2017 COD.

[person pointing at set of gears]

"Patients are best served when their care is provided by an integrated practice care team led by a physician," says the second sentence of that policy.

However, success of team-based care seems to have stalled in recent years.

The authors of an article published in the July/August issue(www.annfammed.org) of Annals of Family Medicine say there's a reason why. They contend that "primary care teams are underpowered."

"They are underpowered because they do not maximally redistribute team functions," write corresponding author Thomas Bodenheimer M.D., M.P.H., and co-author Christine Sinsky, M.D., vice president of professional satisfaction at the AMA, in an article titled "Powering-Up Primary Care Teams: Advanced Team Care with In-room Support."

Story Highlights
  • In an article published in Annals of Family Medicine, researchers describe a new team model dubbed "advanced team care with in-room support."
  • The authors contend that in the old team model, primary care teams are underpowered.
  • Practices that have implemented the new model have seen increases in productivity, net growth, capacity to accept new patients, and patient and staff satisfaction.  

However, "a new team model is bubbling up across the country with the potential to reinvigorate primary care," they add.

This new model comes with a bit of twist and has been dubbed "advanced team care with in-room support." The authors explain that in this core team model, each physician is paired with two or three highly trained medical assistants or nurses -- referred to as care team coordinators.

"This model extends the clinician visit into a team visit," say the authors, with a care team coordinator beginning the visit by completing a number of tasks, including taking an initial history, reconciling medications, addressing chronic and preventive care gaps, and setting the visit agenda based on patient concerns.

The physician joins the visit after 10-15 minutes, "sits face-to face with the patient (without the computer dividing her attention)," expands the history and does a focused physical exam. The physician talks with the patient about a diagnosis and a care plan while the care team coordinator types notes and enters documentation into the EHR.

The team coordinator stays with the patient to review the care plan; set up referrals, labs and follow-up visits; and provide health coaching as indicated.

Meanwhile, the physician moves on to the next patient, where a second team coordinator is already completing the initial tasks.

The Evidence, Please

The authors explain how this model makes "primary care more satisfying to clinicians, staff and patients while enhancing quality."

They cite evidence of successes achieved at early demonstration sites, including practices in Ohio, Wisconsin and Colorado where advanced team care with in-room support has been implemented and where "robust evaluation is ongoing."

That evidence is compelling. For instance, practices report benefits that include

  • increased productivity of as much as 20%,
  • growth in net revenue of 10.5% per encounter,
  • increased capacity to accept new patients,
  • improved blood pressure and diabetes control,
  • improved performance on quality measures, and
  • increased patient and staff satisfaction.

At Bellin Health in northeastern Wisconsin, where the model was piloted in 2014, the authors note that "clinician satisfaction went from 34% without the team model to 88% with the model."

And at the University of Colorado Health System, physician burnout dropped from 56% to 28% just one year after implementing advanced team care with in-room support.

Ripping Away Barriers

Implementing this new model requires a change in mindset that includes redistributing team functions that would "allow clinicians to shed that portion of clinical and administrative work that a well-trained, well-staffed team could easily perform," say the authors.

They discuss the downside of technology and point out that in health care, the EHR "has added rather than subtracted work." Tasks that used to take mere seconds now require minutes, they say, and "work previously done by others has now been shifted to physicians."

The authors say advanced care team with in-room support is all about creating teams in which well-trained support personnel "can assist with the clinical care of patients and assume much of the administrative burden."

"By distancing the EHR from the patient-clinician interaction, technology assumes its rightful supportive role," they add.

Additional Author Thoughts

Bodenheimer, founding director of the Center for Excellence in Primary Care(cepc.ucsf.edu) at the University of California, San Francisco, Department of Family & Community Medicine, told AAFP News that he spent 32 years as a general internist in a low-income San Francisco community. In the following Q&A, he provides additional comment about this article.

Q. Why is this discussion important at this juncture in the U.S. health care system?

A. Family physicians are dealing with large patient panels, frustrating EHRs and exhausting administrative work. The existing model is not sustainable. Physicians need teams with well-trained personnel to take on both clinical and documentation tasks.

Q. What are some of the barriers to widespread adoption of this model?

A. As the commentary argues, there are significant obstacles. First and foremost, the financial leadership of the health system in which the primary care practice is situated must understand that there is a business case for hiring two or more clinical assistants per physician.

Second, there needs to be a physician champion who pilots the new model, adapts it to his or her practice, and then creates and leads a robust training program.

Third, there needs to be an evaluation after the model is in place to determine if physician and patient satisfaction increases, clinician burnout decreases, quality of care is preserved, and financial performance improves.

Q. Is it possible to get physician buy-in at the individual level?

A. Yes, if a few things go right (and they should):

  • if the burden of EHR documentation is virtually eliminated from the physician's day,
  • if clinical assistants do a good job and quality markers and patient satisfaction go up,
  • if physicians can eliminate the burden of documentation tasks after they've put their kids to bed.

If these things happen, physician burnout will decrease, and I would expect to see almost 100% buy-in, because that is what has happened in the practices that piloted the advanced team care with in-room support model. Physicians were begging to start the new model.

Q. What's the most important takeaway for family physicians?

A. It's becoming increasingly hard for family physicians to sustain a primary care practice. This model allows them to focus exclusively on their patients without the interference of EHRs and documentation tasks. Importantly, this model gets physicians out of the clinic earlier and without take-home work.