Overview

• This intervention sought to adopt integrated practice units (IPUs) into a primary care practice using ‘pod’-based patient care with a multidisciplinary team, disease-oriented patient registries, and restructured clinic schedules around patient time in an effort improve efficiency and continuity of patient care.

Organization Name

Union Square Family Health Center, Cambridge Health Alliance

Organization Type

• Community health center
• Safety net hospital

National/Policy Context

• Michael Porter and his colleagues at Harvard Business School defined the concept of the integrated practice unit (IPU), a team of clinical and nonclinical members providing integrated outpatient and inpatient care for a particular medical condition or group of related conditions.
• The IPU has been implemented across multiple specialties at different organizations nationwide, such as at the Neurological Institute at Cleveland Clinic, which integrates neurology, neurosurgery, and psychiatry services for stroke care.

Local/Organizational Context

• Union Square Family Health operates in an urban, low-income, culturally-diverse neighborhood with a significant population of uninsured immigrants. Union Square Family Health is one of Cambridge Health Alliance’s twelve neighborhood care centers.
• Cambridge Health Alliance is an academic community health system serving patients in Cambridge, Somerville and Boston’s metro-north region. It has the highest concentration of Medicaid and low-income patients among Massachusetts hospitals, including three times for Medicaid and low-income public payor patients and 4.4 times more uninsured care than the average acute care hospital.

Research + Planning

• The clinic’s patients were organized into “pods” of 4000-5000 patients. Each pod’s care team consisted of 2-3 primary care physicians, 1.5 physician assistants, 1.5 nurses, 1 receptionist, and 3-4 medical assistants. Roles for major team members included:
  • Medical receptionist: Receptionists were members of the local community and cultural ambassadors for the clinic, being familiar with each pod team’s patients and their families. They helped with immunization and appointment scheduling.
  • Medical assistant: MAs assisted with blood pressure checks, immunizations, and other clinical activities. They also coordinated with physician regarding care needs for patients on a given clinic day. Additionally, they conducted outreach for screening and prevention to their pod.
  • Registered nurse: Nurses were involved in chronic disease management via essential patient education, outreach to complex patients, and management of transitions of care.
  • Physician assistant: PAs shared a pod with physicians. In some cases, patients received care solely from PAs, resulting in about 90% continuity for PAs.
  • Physician: Physicians provided diagnostic and therapeutic clinical care for patients. Patients were assigned one physician but could see a different physician or PA in the pod if their designated physician was unavailable, or if the patient had specific preferences (e.g. preferring a PA fluent in the patient’s native language).
• Other major components of the integrated practice unit include use of disease-based patient registries (see ‘Tools or Products Developed for Project’) and a restructured clinic schedule based around patient time and emphasizing team based care (see ‘Daily Schedule Workflow’).

Tools or Products Developed

• Patient Registries: the clinic created patient registries for 20 chronic medical conditions, such as diabetes, depression, and hypertension, that encompassed patients across all the pods and allowed for monitoring across clinic visits. Each registry had designated staff members who met weekly during ‘planned care meetings’ for all patients with that given condition. These registries allowed designated staff members to be responsible for specific patients in terms of providing care during clinic and conducting appropriate follow-up.

Tech Involved

• Registry

Team Members Involved

• Administrative Assistant
• MAs
• NPs
• PAs
• Physicians
• Primary Care Physicians
• RNs

Workflow Steps

• The day before a clinic session, the medical assistant and primary care physician meet to create a care plan for immunizations, lab work, and screenings for each patient on the clinic session list for that day and add this plan to the EHR for clinic members to carry out the following day.
• The clinic has a flexible schedule that is oriented to meet patient needs and account for patient complexity and acuity.
  • For example, a typical morning might start with a group huddle involving all team members. An NP and medical assistant will begin to triage acute patients together, while a physician attends to e-visits/phone visits and a second medical assistant conducts activities related to panel management. In the meantime, the team’s RN may follow up on patients recently discharged from the hospital or outreach to other patients. After that, the physician and medical assistant might see some patients together with complex conditions. The primary care physician may spend some time coordinating with external providers before having a group huddle with the RN and NP.
• Screenings and other tasks are carried out when the patient arrives and/or after the patient is seen by the primary care provider.

Figure 1: Sample Clinic Schedule

Budget Details

• Development of disease registries and new flowsheets/forms for care plans.

Where We Are

• This intervention is ongoing.
• The model of care continues to be refined at Union Square Family Health. For example, there is currently no integration of specialists to perform screenings such as mammograms and colonoscopies, and Cambridge Health Alliance hopes to involve specialists more in care coordination in the future.

Outcomes

• Average yearly visits: Patient needs were being met more efficiently during visits. Three years after implementing integrated practice units, average yearly visits dropped from 3 to 1.5 per year.
• • Organizational quality metrics: Cambridge Health Alliance tracked 20 process measures and laboratory-based endpoints for prevention, disease management, and complex care across its clinics; in 2016, Union Square Family Health met or exceeded targets for 15 of the 20 measures:
    • Pediatric immunization: Perfect care immunization for children ages 0-2; HPV, tetanus, and menactra immunizations for adolescents
    • Tobacco use screening and intervention: Screening and counseling for adult patients and patients aged 11-17
    • Cancer screening: Breast, cervical, colorectal cancer screening
    • Mental health screening: Developmental screen for children; depression and substance abuse screening for adults
    • PHQ-9 depression scores: 50% reduction in PHQ-9 depression scores — Follow-up PHQ-9s and optimal contacts for patients with depression
    • Well-child visits: Well-child visits for all 0-15 months, 3-6 years, and 12-21 years old
    • Diabetes optimal outcome measures: Hemoglobin A1c < 8, blood pressure < 140/90, & nonsmoker
    • Diabetes optimal process measures: 2 hemoglobin A1c tests, 1 microalbumin, 1 screen and intervention (if needed) for tobacco, & 1 PHQ-9 depression screen
    • Cardiovascular optimal outcome measures: Patients with hypertension diagnosis whose last blood pressure measurement is < 140/90
    • Asthma optimal process measures: Long-term medications, Asthma Control Test, Asthma Care Plan, and flu vaccine given
    • Care plan usage: Care plans for patients with diabetes (hemoglobin A1c greater than or equal to 8), depression (PHQ-9 greater than or equal to 15), asthma, and complex care
    • Hospital follow-up: Contact follow-up within 2 days and 7 days of hospitalization
    • Emergency department follow-up: Contact follow-up within 7 days of emergency department visit

Benefits

• This care model allows for efficient, patient-centered, and value-based care.
• By being a part of a specific ‘pod,’ patients are able to see a consistent group of clinicians specific to that pod whenever they come to a visit, allowing for continuity of care. Primary care providers have a smaller effective panel size.
• The improved workflow under this model has allowed for more efficient use of patient and staff time because the schedule of the clinic is organized around patients instead of around physician appointment slots.
• Preventive care is better integrated into patient visits and follow-up.

Unique Challenges

• Current reimbursements to Union Square Family Health do not incorporate time for care planning, nurse visits, and pharmacist teaching, which are integral parts of this care model and can lead to financial losses for fee-for-service reimbursed practices. Capitated payments and/or bundled reimbursements would help to address this issue.

Sources

Jain, N., Okanlawon, T., Meisinger, K., and Feeley, T. Leveraging IPU Principles in Primary Care. NEJM Catalyst. https://catalyst.nejm.org/integrated-practice-unit-ipu-primary-care/. Accessed February 3rd, 2019.