Team Effort

Patient-care Models Show Many Practice Benefits

By Bonnie Darves
Bonnie Darves is a writer for Physicians Practice

Ask physicians in a typical U.S. medical practice whether they would consider modifying care delivery by implementing dedicated patient-care teams, and many are likely to respond: “What do you mean? We already work as a team in our practice.”

Charles Kilo, M.D., M.P.H., begs to differ. Kilo, a fellow of the Institute for Healthcare Improvement, is well known for his provocative, often controversial views on the challenges and shortcomings of the traditional office-based practice. Kilo doesn’t believe that what many medical professionals describe as a team meets the true definition of the term.

“We use the word a lot, but when you really talk about constructing a multidisciplinary team in a practice, it works fundamentally differently than the way most practices operate. And it’s hard to find,” said Kilo, co-founder of GreenField Health System, a Portland, Ore., practice that incorporates many principles and components of IHI’s Idealized Design of Clinical Office Practices (IDCOP) initiative: open access, customized communication and a population-based approach to care.

Many physicians, by virtue of their training, view their work as being primarily in the exam room, in the one-on-one encounter with the patient, Kilo said. That’s why the notion of delegating responsibility and working as part of a true team — a highly coordinated group of individuals who operate by a common playbook and share responsibility for outcomes — is foreign to many physicians.

Yet for the practices that commit to changing the status quo and moving toward care teams, the potential benefits are myriad. Care management and patient follow-up are more efficient, Kilo maintains, mostly because physicians are relieved of tasks that can be performed just as well or even better by other team members. “It’s all about efficiency — theoretically, at least. If you offload work from the most expensive resource, the physician, you can ‘kick up’ the horsepower in the practice,” he said. For example, when team members are adequately trained and protocols are in place, much of the routine care provided to patients with conditions such as hypertension and diabetes can be delivered by nonphysician staff.

Multidisciplinary patient-care teams — those in which nonphysician providers, such as nurses, assume expanded roles in patient management — have already proved effective in the intensive-care unit setting and in the management of patients with chronic illness. Today, some forerunning practices and organizations are finding that the team model produces operational quality improvement and even financial benefits, regardless of the care setting or patient demographics. Following are profiles of two practices that have taken the team model to new levels:

Teams in a multisite practice
At Primary Care Networks in Dayton, Ohio, patient-care teams have developed in a highly defined, practical manner. Each of the 100 physicians in the 36-site network works with certain staff members — a receptionist, a clinical staff member (R.N., L.P.N. or medical assistant) and additional nursing support, depending on the patient-population demographics. The team functions in a dedicated work area in which exam rooms, supplies and even telephone lines are devoted specifically to the team. In addition, each team decides how tasks will be allocated among its members and operates as its own business unit, which means the team generates its own financial and outcomes data.

That relatively straightforward, if unusual, team structure yields a number of benefits, said Evan Steffens, R.N., director of clinical and quality systems for the practice network, which is affiliated with Premier Health Partners. Chief among them is that team members come to know their patients well enough to avoid the time-consuming triage and time-wasting task shuffling that can occur when patients call a large practice.

“You get tremendous efficiency by having people responsible for a smaller piece of the pie,” Steffens said. “When patients call in and the receptionist knows them, they can appoint that person more quickly than someone who barely knows them. And patients have more trust in the process because they know who they’re talking to.”

It also helps avoid an issue frequently cited by physicians: improper or inadequate patient screening on the front end. It’s far easier for a receptionist to “learn the ins and outs” of a panel of patients for one physician than for six different physicians, Steffens notes. And when staff members know patients well, they’re more likely to pick up on unspoken needs that arise during a scheduled visit — such as the diabetic patient who calls because of a sore shoulder but may need a more extensive examination or lab work because she hasn’t been seen by her physician for six months.

Moving from a formerly centralized model to dedicated practice teams has been no small feat, acknowledges Steffens, who, before joining Primary Care Networks, helped lead the transition to a decentralized structure at Seattle-based Group Health Cooperative. Physicians and staff members first have to be educated on and convinced of the potential benefits of practice teams. Then there’s the thorny task of determining who is assigned to which team. (Both staff members and physicians are asked to list their top three choices for team members, but trouble can occur when lists don’t match up well.) In addition, some people, including physicians, may resist the idea of working on a team or of being tied to a particular group.

But once those hurdles are cleared, the payoffs accrue. At Primary Care Networks, physician and staff satisfaction, visit cycle times and financial performance have all improved since the organization began implementing practice teams in 2000. “There has been a big improvement in staff satisfaction. They like being part of their own little company, and there is more accountability,” Steffens said, noting the marked drop in call-in rates. “People are more likely to show up when they know their team is depending on them.”

The shorter visit time, from about 65 minutes in 2000 to an average of 40 minutes this year, is responsible in part for the significant financial improvement Primary Care Networks is experiencing. But the reduced salary overhead — there’s less overtime and less need to cover employees who call in sick now — has contributed to the improved bottom line as well, according to Steffens.

The new team structure also has been well-received by physicians, primarily because it simplifies their workday and makes it easier to identify and remedy problems when they occur. “The [physician] response has been very positive for the most part,” Steffens said.

Physician delegation pays
For Primary Care Partners, P.C., the decision to create patient-care teams grew out of a basic desire to improve in a number of areas. The Grand Junction, Colo., organization, comprised of three offices and 15 physicians, first implemented a chronic-care model for depression as part of an Institute for Healthcare Improvement collaborative. It then turned its sights to open-access scheduling.

Primary Care Partners was also a forerunner in using electronic medical records (EMRs), which it implemented in 1993. A few years later, to meet community need and in response to its own business concerns as part of an Independent Physician Association (IPA), the group started an after-hours urgent care center.

“I guess you could say we’ve been working on ‘being a first’ for awhile,” said Gregg Omura, M.D., a family medicine physician and partner in the group. “The open-access scheduling and the team model, which we started about three years ago, were outgrowths of the improvement work we were doing.”

At Primary Care Partners, the team-care model is both lean and rich. Lean because Omura is the only physician; rich because his teammates — three clinically trained staff members and a receptionist — comprise a well-oiled machine that enables patients to move through the practice in a relatively seamless manner.

At the heart of Omura’s team model are training and trust. The clinical staff assume many tasks generally done by physicians, such as initial patient histories, work-ups for routine physicals and symptom reviews. “The basic idea is that I don’t do anything that doesn’t require an M.D. after my name. So the nurses do the initial history, which is a lot more satisfying for them than just taking vital signs because they interact with the patients more, and they learn new skills,” he said.

“What it means for me is that I’m not doing all the paperwork and that I don’t walk out of the exam room to get samples or to do anything else,” Omura said. It is, in some senses, an almost complete reversal of a traditional office practice — with three back-office, clinical support staff instead of the typically larger front-office staff.

Oddly, implementation of the team model hasn’t markedly changed Omura’s patient-encounter time, except on the low end of the scale. Because his clinical staff has dealt with the initial assessment, he might spend just a few minutes with a “single-complaint” patient (for example, someone with an ear or urinary tract infection). And, he is freer to spend more one-on-one time with a patient who has several problems. “It’s worked out better that way because I’m not taking histories on every patient who comes in,” he said.

Omura admits this concept is not something that can be easily implemented in short order. Ensuring the practice has a well-trained, trusted team is a major prerequisite. “The history-taking component is the most important part of this model, so that means the nurses and other staff have to be very good at taking a good patient history, and it means the physician and staff have to be very good at assessing things like chest pain, when you don’t want to trust or rely on the history,” he said, adding that the EMR templates provide invaluable history-taking assistance.

“You have to feel comfortable with delegation, capable of working as part of a team and — most important, perhaps — confident in letting nonphysician work be done by nonphysician staff,” he said. Still, Omura added, he routinely takes the time to go over, at least briefly, all of the elements of the history and complaints with the patient.

How has the team model worked out operationally and financially for Omura and Primary Care Partners? Better than expected. He was seeing about 20 patients a day before he moved to the team-care model. Within a year, that number increased to 28 on average; now it’s approaching 35. Even with that, Omura said he’s not spending more time in the office than he did before, and he has the sense that he’s working less hard than he once did.

His financial picture is improving in tandem. “My personnel charges have gone up, but my charges and my income have gone up more substantially — about 10 percent to 15 percent each of the past three years,” he said. On balance, Omura said, he is coming out well ahead of the game in improved quality of life, and the practice is experiencing greater staff and patient satisfaction.

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