NP-MD primary care teams were created to address clinician burnout and increase patient access in an urban safety-net hospital.
Boston Medical Center General Internal Medicine
- Academic Medical Center
- Safety net hospital
- Rates of clinician burnout, dissatisfaction and stress in the practice were higher than the national average, driving interest in alternate care models.
- Administration of the Mini Z Burnout survey in 2018 showed higher rates of dissatisfaction (38.1% vs 24.5%), job stress (69% vs 67%), and symptoms of burnout (47.6% vs 38.2%) among providers in the General Internal Medicine department compared to the national average.
- Prior to the establishment of NP Anchor, NPs in BMC primary care had their own patient panels. Like full-time MDs in the practice, they had eight half-day clinical sessions and two sessions of administrative time weekly.
Patient Population Served and Payor Information
- The general internal medicine practice at Boston Medical Center serves about 40,000 patients.
- 50% of patients are insured by Medicaid, and 30% of patients are insured by Medicare.
- Dr. Joanna D’Afflitti is the MD lead
- Melissa Jacobs, MSN ANP-C is the NP lead
- The intervention sought funding from BMC. Discussions with hospital leadership about the importance of the intervention included emphasizing:
- The value of retaining physicians over supporting two NP between-visit sessions per week
- The increase in clinical capacity with additional NPs
- The potential for improved quality of care and better management of high-risk/high-cost patients, especially in the context of an accountable care organization payment model
Research + Planning
- This program is based on a model developed by East Boston Neighborhood Health Center.
- In an initial pilot, two NPs co-managed 70 medically complex patients with eight physicians. Teams were then added every one to two months over an 11 month period until a total of 10 NPs and 31 physicians were on NP-MD teams.
- NP and MD selection:
- Several new NPs were hired as part of the NP-MD teams. A few NPs who had been in the practice for the long time and were accustomed to managing large enough patient panels decided to stay in their original NP roles.
- MDs were selected to participate in the new care model depending on their willingness to be on a care team, burnout risk, and volume of patients.
- Team duties
- Each team decided the content of NPs’ between-visit work, determined which areas of co-management were most helpful, and organized communication logistics.
- Business cards with MD and NP names were created.
- NP and MD selection:
- Call center staff, clinic staff (front desk, medical assistants, patient navigators), and nurses were all educated about the model and trained in how to explain it to patients, particularly when the staff schedule a patient to see the NP on the care team.
- Physicians and NPs engage in on-boarding session and team meetings when they begin participating in the model. They continue to meet regularly after on-boarding as a group (at least once per month).
Team Members Involved
- Administrative Assistant
- Support Staff
- Scheduling templates denote composition of care teams, allowing staff to schedule patients with appropriate MD or NP in the new care model.
- NPs have six half-day clinic sessions a week and see patients on their team or through urgent care. On average, one NP is paired with three to four physicians (1 full-time equivalent NP to 1.5 FTE physicians).
- NPs have two sessions of protected/budgeted time for between-visit care. During these sessions, they engage in patient outreach and tasks such as adjusting medications by phone, following up on test results, chronic disease management, care coordination with specialists, and scheduling preventive care such as colonoscopy.
- During patient visits, MDs made warm handoffs/introductions to their NP partner. Physicians and staff educated patients during appointment scheduling and during visits about the new care model.
Includes the NPs’ two additional “protected” sessions per week
Where We Are
Currently the entire department’s practice works under this model.
- Time to appointment: The average time to the next available appointment with a team provider (NP or MD) decreased by about 20 days, due to greater clinical capacity provided by NPs.
- Clinician retention: During the 11 month period of the study, 1 NP and no physicians on NP-MD teams left the practice, compared to 1 NP and 3 physicians not participating in team-based care.
- Clinician satisfaction:
- 79% of physicians surveyed thought the new care model was very/extremely helpful in decreasing the burden of work between visits. 92% of them found the model to be very/extremely helpful in increasing access and all physicians felt their teams worked together very/extremely well.
- 100% of the 9 nurse practitioners in the NP-MD care teams surveyed were very/extremely satisfied with their job and indicated their care team worked together very/extremely well.
- Clinician satisfaction:
- The project leaders will continue comparing burnout among physicians and NPs on the teams to other physicians.
- They will continue to evaluate quality measures (e.g. cancer screenings and diabetes control among patients with poorly-controlled hemoglobin levels).
- They will standardize practices across teams to create a more consistent provider experience.
- They will compare patient experience under the NP Anchor model to standard care.
- This model has improved access to care and continuity for patients. In the past, because some physicians worked part-time in clinic and had limited availability, patients would not get to see the same physician. Now, the patient can have an appointment consistently with a given physician or a given NP.
- The program has led to increased hiring of nurse practitioners, which promotes professional diversity in internal medicine and has allowed for the creation of the NP lead role.
- NP and physician satisfaction have improved. Physicians feel like they have someone to share work with, and NPs are able to provide better follow-up. NPs still have a cohort of patients and can still make their own decisions and adjust meds independently. However, they can also co-manage and check in with physicians.
- Obtaining patient buy-in was a challenge. Providers needed to explain to patients the concept of the team instead of a single provider and provide education about the benefits of the NP-MD care model.
- Providers and staff had to get used to the idea of co-management. Providers were initially not used to sharing patient care.
- The transition to a new care model involved a lot of logistics given the large size of the practice. For example, the practice had to ensure the patients were scheduled with the right providers.
- Team members needed to arrange time to check in and discuss patients and their care as a team.
- Study limitations: a small sample size of NPs from which to draw feedback/infer outcomes from, a lack of comparison to standard care.
- Conversation with Dr. Joanna D’Afflitti. Input from Melissa Jacobs
- DʼAfflitti J, Lee K, Jacobs M, Pace C, Worcester J, Thornton S, Lasser KE. Improving Provider Experience and Increasing Patient Access Through Nurse Practitioner-Physician Primary Care Teams. J Ambul Care Manage. 2018 Oct/Dec;41(4):308-313.
- Joanna D'Afflitti, MD, MPH
- Melissa Jacobs, NP-C, MSN
- Jacqueline You, BA
Boston, MATalk to the Innovators