EXAMPLES OF HIGH-FUNCTIONING PRIMARY CARE PRACTICES
In 2013, a team of primary care leaders and researchers visited “23 high-functioning primary care practices,” 4 and observed innovations these practices have implemented to overcome common problems.
The following activity highlights specific innovations that have been introduced in high-functioning primary care practices to provide patient-centered medical home care for patients. Many of these are small incremental changes that can be implemented by individual clinicians or clinical teams. We will need both incremental changes and bigger systemic transformations and redesigns to achieve value-based health care.
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PROBLEM
Unplanned visits with overfull agendas
INNOVATION
- Previsit planning
- Preappointment laboratory tests
SOLUTION IMPLEMENTATION
At Mayo Red Cedar Medical Center patients have their laboratory tests done a few days before their appointments and are able to discuss results and engage in shared decision making at the time of the visit. This system eliminates an hour or more per day of post-appointment results reporting. Many high-functioning sites have learned that previsit planning and previsit laboratory tests can reduce the total volume of work to be done, save time, and improve care.
Source: " In search of joy in Practice: A report of 23 Hight-Functioning Primary care Practices";
Sinky, CA, et al. Used with permission.
PROBLEM
Inadequate support to meet the patient demand for care
INNOVATION
- Sharing the care 1
- Expanded nurse or medical assistant rooming protocol
- Standing orders
- Extended responsibility for health coaching, care coordination, and integrated behavioral health to nonphysician members of the team
- Team responsibility for panel management
SOLUTION IMPLEMENTATION
Improving access and increasing adherence to clinical guidelines requires building additional capacity into the practice. Many sites accomplished capacity building by transforming the roles of medical assistants, licensed practical nurses, registered nurses, and health coaches so that they assume partial responsibility for elements of care. In addition, some practices have an extended care team of social workers, behavioralists, nutritionists, and pharmacists, usually working with several clinician–medical assistant teamlets. At North Shore Physicians Group (NSPG) in the Boston area, the medical assistant’s role has been transformed. When a patient is taken to an examination room (rooming), the process has been expanded from 3 minutes to 8 minutes and now includes medication review, agenda setting, form completion, and closing care gaps. For example, the medical assistant reviews health-monitoring reminders, gives immunizations, and proactively books appointments for mammograms and DXA (dual-energy x-ray absorptiometry) scans for osteoporosis.
Source: " In search of joy in Practice: A report of 23 Hight-Functioning Primary care Practices";
Sinky, CA, et al. Used with permission.
1These roles require 2- 1 or 3-1 clinical support per physician
PROBLEM
Great amounts of time spent documenting and complying with administrative and regulatory requirements
INNOVATION
- Scribing
- Assistant order entry
- Standardized prescription renewal
SOLUTION IMPLEMENTATION
Empowering nurses and/or medical assistants to become an integral part of the visit: scribing the note, entering orders, preparing the after-visit summary, and reinforcing the plan with the patient. At the Cleveland Clinic Strongsville, primary care physicians work with 2 medical assistants or 1 medical assistant and 1 registered nurse. The nurse or medical assistant first completes an expanded rooming protocol, then returns with the physician to record notes while the physician talks with and examines the patient.
Source: " In search of joy in Practice: A report of 23 Hight-Functioning Primary care Practices";
Sinky, CA, et al. Used with permission.
PROBLEM
Computerized technology that pushes more work to the physician
INNOVATION
- Inbox management
- Verbal messaging
SOLUTION IMPLEMENTATION
In several practices the nurse or medical assistant filters all the electronic and paper information, passing on to the physician only that information which specifically requires a physician’s level of expertise. In addition, replacing asynchronous electronic messaging with verbal messaging reduces the volume of in-box messages.
Fairview Clinic in Minneapolis has decreased inbox work from 90 minutes to only a few minutes per day for many physicians. All messages are first directed to the medical assistant or nurse, who filters out normal laboratory results, prescription renewals, or requests that can be managed by protocol, passing through to the physician only messages that require physician-level attention.
Whenever possible, electronic messaging is replaced by more time-efficient verbal messaging between nurse and physician.
Source: " In search of joy in Practice: A report of 23 Hight-Functioning Primary care Practices";
Sinky, CA, et al. Used with permission.
PROBLEM
Teams that function poorly and complicate rather than simplify the work
INNOVATION
Improving team communication through
- Co-location
- Huddles
- Regular team meetings
- Improving team functioning
- Systems planning
- Work flow mapping
SOLUTION IMPLEMENTATION
Co-location can make minute-to-minute communication more efficient. Team meetings provide protected time to improve processes and strengthen trust and reliance among the team. In the care team model at North Shore Physicians Group (NSPG) the medical assistant and physician sit side-by-side in “flow stations.” One of the early adopters was an established physician with a large panel of patients (2,500) with highly complex conditions. Previously this physician took 2 to 3 hours of work home each night; with co-location that facilitates efficient verbal communication and the expanded role for medical assistants, he routinely leaves the office with all of his work completed.
Source: " In search of joy in Practice: A report of 23 Hight-Functioning Primary care Practices";
Sinky, CA, et al. Used with permission.
