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Team-Based Primary Care Redesign

Keywords: Team, Primary Care

Overview

Development of a team-based care process at a small suburban primary care practice

Innovator

Alison Landrey MD

Editor

Lisa Rotenstein MD

Location

Aesculapius Medical Center at the University of Vermont, South Burlington, Vermont

Organizational Context

  • Clinic is a suburban primary care practice affiliated with an academic medical center (University of Vermont)
  • In preparation for moving away from fee for service payment, sought to enhance team based care
  • Practice consists of 12 providers (MD or NP); standard model includes loose partnership of all nurses with all providers 

Population Served

  • Practice sees 12,000 patients yearly.
  • Mostly an older patient population.
  • Although the practice takes all insurance types, most patients have Medicare. Not many patients are uninsured.
  • Almost all patients speak English. There is a sprinkling of other populations (diverse refugee populations, Vietnamese speaking patients)
     

Project Research and Planning

  • Two years ago, practice started a one year pilot to develop team based care protocols for two physicians’ panels
  • Planning took about six months; sequential planning meetings were held within the practice
    • Meetings took place weekly throughout the year. Usually all team members attended. The agenda involved discussing implementation barriers and PDSA cycles.
  • Teamlets of a physician and a nurse practitioner were relocated to be physically colocated; they worked alongside RNs, an LPN, and an MA associated with the program
  • Practice protocols were developed for non MD or NP practitioners to fulfill new roles that enabled them to work at the “top of their license”
    • Protocols were developed by team members in an iterative process (e.g. there was a workgroup for defining protocols for new patient visits, a workgroup for protocol development for RN BP visits, etc.)
    • Tasks considered “top of the license” for each role were defined by the University of Vermont
  • New appointment types were created for LPN or RN visits. Although it took some time to figure out the right length for these appointments, they ultimately were 15 and 30 minutes, respectively.
  • Physicians and NPs also had increased time built into their schedules for non face-to-face visits (90 minutes daily for NPs, 30 minutes daily for MDs)
  • Two month PDSA cycles refined each role and teamlet functioning
    • PDSA cycles occurred for 10 specific innovations within the team model

Project Tools and Components

  • Smartphrases built to support the program - i.e. RNs had Epic-based smartphrases to click through during visits

Funding

  • Funds derived from the University of Vermont

Team Members

  • 2 physicians
  • 2 NPs 
  • 2 RNs
  • 3 LPNs
  • One MA
  • One practice manager (non-medical)

Daily Workflow Steps

  • Patients seen for chronic disease follow up would be alternatingly scheduled with their MD PCP or with the PCP’s NP to enhance access to care
  • RNs gained responsibility for triaging all inbound calls into the practice; instead of front desk staff automatically booking appointments, RNs took calls and decided whether patients should be seen same-day in the practice. 
  • Protocolized visits were set up which RNs/LPNs could conduct by themselves, either as separately booked appointments or as adjuncts to PCP/NP appointments
  • RNs conducted protocolized medication reconciliation, hypertension and diabetes follow up visits
  • The latter were focused on logging diabetes information and follow-up of diabetes management
  • LPNs conducted BP follow up visits at which they could quickly document home BP values, correlate patient home BP cuffs and route them data to doctors
  • LPNs also conducted follow-up calls after patients visited urgent care and emergency departments to see how patients were doing and assess for a need for in-person follow up
  • LPNs could do after visit summary reviews with patients, schedule any needed follow up prior to check-outand check them out in the exam room instead of patients returning to the front desk for check out.

Budget

Exact cost unknown

  • Main cost derived from greater RN and NP capacity in the pilot versus usual care. The University of Vermont, who provided the directive for the pilot, funded this extra RN and NP capacity.

Status

Intervention is not ongoing

Key Outcome

Urgent care utilization + time to next available appointment

Outcome Analysis

  • Trend towards reduced urgent care utilization
  • Improved access to provider schedules (time to 3rd next available appointment decreased)
  • For example, for one provider, the time to the next available follow up visit decreased from ~39 days to ~1 weeks
  • Perceptions of team members involved in the pilot:
    • 9/9 reported greater satisfaction and improved patient care coordination
    • 8/9 felt they were practicing to a fuller extent of their license and described that patients had improved access to care. 

Future Outcomes

  • Similar smaller pilots (one intervention at a time, e.g. RN Medicare visits, scheduling non face-to-face encounters) are happening at various other University of Vermont sites to consider how to expand team based care into daily schedules

Benefits

  • Practitioners got to know each others’ workstyles very well
  • Expanded scope of RN/LPN roles
  • Enhanced continuity of care for patients with their personal care team
  • Practitioners felt they were providing better care

Unique Challenges

  • The pilot teams were small, so if someone was out of the office - i.e. an LPN -it was harder to replace their unique skill set than with that of any other LPN who was not similarly trained

Personnel Challenges

  • Any interpersonal challenges were amplified within a small team setting
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