Overview
The care team at Bellin Health Center holds weekly interdisciplinary meetings for discussion of high-risk patients in order to alleviate health worker burnout and to improve the health outcomes of their patient population.
Organization Name
Bellin Health System
Organization Type
- Integrated healthcare system/network
National/Policy Context
- Significant rates of clinician burnout have been documented, which is thought to be driven largely by the increasing demands of the electronic health record.
- The increasing complexity of care has led to the increased prevalence and greater recognition of the value of creating a team-based approach to the care of patients.
Local/Organizational Context
- Physicians and other practitioners at the organization expressed dissatisfaction and endorsed symptoms of burnout, leading to the initiation of this program in February 2014. The intervention was designed not only to address these issues, but also to improve population health and allow the organization to provide value-based care.
Patient Population Served and Payor Information
- Bellin Health System serves patients in northeastern Wisconsin and the Upper Peninsula of Michigan.
- Currently, 171,000 patients have a Bellin primary care physician or advanced practice clinician (APC) as their primary care provider.
- 50% of patients have commercial insurance, 32% of patients have Medicare, and 13% of patients have Medicaid.
Leadership
- James Jerzak M.D. is the physician lead for Team-based Care.
- Kathy Kerscher is the Director of Primary Care and administrative lead for Team-based Care.
Funding
- The program was internally funded and did not require grant money or outside support.
Research + Planning
- The planning team included 2 physicians, 2 advance practice clinicians, and 6 system administration representatives.
- Six months of planning occurred prior to the launch of the prototype, with activities including:
- Researching the growing body of literature on team-based care
- Communicating with national thought leaders
- Site visits to existing team care locations
- Weekly meetings to develop the model for advanced team-based care, to develop the infrastructure needed for this transformation, and to plan the launch of the prototype
- Three changes borne out of the redesign process included:
- Complete redesign of the office visit workflow featuring enhanced roles for certified medical assistants (CMAs) and licensed practical nurses (LPNs) in domains including the electronic health record and documentation support
- Redesign of in-between visit work, featuring redesigned in-basket workflows, team approach to in-basket work, and enhanced roles for care team registered nurses (RNs)
- Development of system and community resources to aid teams in the care of complex and high-risk patients
Tools or Products Developed
- Playbook: The intervention required development of a playbook for teams to use as a guide while implementing the intervention
- Training protocols: Intensive training protocols were developed for each role (See Training for Project).
- Training camp: The organization created an annual training camp for Team-based Care at Lambeau Field, the home of the Green Bay Packers in Green Bay, Wisconsin. The fourth camp is planned for April 20-22, 2020.
Training
- Training involved all team members:
- CMAs/LPNs: Training in documentation and electronic health record specifics, care gap closure, medication review, basic health coaching
- RNs: Training for expanded roles in direct patient care, including Annual Medicare Wellness visits, blood pressure follow-up visits, Medicare Chronic Care Management and Medicare Transitional Care Management, and diabetes education. They also received training in motivational interviewing.
- Physicians: Training on working as part of a team
- Entire Team: Training in population health basics, team culture, and change management.
- Electronic health record training: The week prior to go-live, teams sat together for a three-day electronic health record training, developing templates and learning to understand all aspects of electronic health record work in terms of team-based care.
Tech Involved
- Electronic medical record
Team Members Involved
- Behavioral Health Specialist
- Care Coordinator
- Case Management
- Health Coach
- NPs
- PAs
- Pharmacist
- Physicians
- RNs
Workflow Steps
- Patient office visit:
- LPN/LMA role:
- Pre-visit planning
- Expanded rooming
- Care gap closure
- Medication review/pending refills
- Agenda setting
- Documentation support
- Pending orders
- Basic health coaching
- In-room scheduling of next appointment and labs
- After visit summary review
- Physician role:
- Fully engage the patient without computer distraction
- Review and sign pended orders
- Review, edit, and sign documentation, preferably before seeing the next patient
- LPN/LMA role:
- In-between visit work:
- Send correspondence to appropriate team member, rather than defaulting items to the physician/advanced practice clinician
- Core team members were co-located to enhance efficiency of this work
- Team approach, with everyone pitching in at the top of their skill set, as time would allow
- Encourage patient portal use to foster efficient communication with patients
- Leverage co-location to decrease the burden of electronic messaging
- Utilize care team RN far beyond traditional triage role, with patient visits (blood pressure checks, Annual Medicare Wellness visits, diabetes education), and key role in Medicare’s Chronic Care Management and Transitional Care Management programs.
- Population health management:
- Engage CMA/LPNs in care gap closure during rooming
- Utilize extended care team to aid with the care of complex and high-risk patients
- Regular meetings of core team members and extended care team members to coordinate care of patients and to focus on quality measure improvement*
- Work with community resources to help meet those with social determinants of health needs
- *Team meetings
- The main primary care team (including physicians, nurse practitioners, physician assistants, etc.) and the extended care team (including case managers, pharmacists, behavioral health clinicians, health coach, and RN Care Coordinator) hold a weekly hour-long meeting regarding high-risk patients:
- During the first half of the meeting, the main primary care team meets alone for a half-hour discussion about the extended care team’s work during the prior week
- Members from the extended care team are then involved in discussions either in person or over the phone for the next half-hour about specific high-risk patients
- After the meeting, care team members follow through on specific action items discussed during the meeting:
- Examples: A care manager may work with a patient to obtain insurance, the health coach may discuss smoking cessation with the patient, a pharmacist may meet with the patient to perform medication reconciliation, and the diabetes educator may set up a plan to improve the patient’s blood sugar control
- The main primary care team (including physicians, nurse practitioners, physician assistants, etc.) and the extended care team (including case managers, pharmacists, behavioral health clinicians, health coach, and RN Care Coordinator) hold a weekly hour-long meeting regarding high-risk patients:
Budget
- $100K to $500K
Budget Details
- Initial budget for planning team and prototype: $250,000
- The model described above requires increased staffing, since busy physicians/APCs require more than one LPN/CMA.
Where We Are
Team-based care has been accepted as the new standard in all specialties of Bellin Health System, including in primary care, speciality care, and acute care. Eventually, care in all specialities, for all conditions, and in all departments will be team-based.
Outcomes
- Patient-centered outcomes:
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- Recommendation rate: Likelihood to recommend their patient experience increased 6.9% from 2017 to 2018
- Patient engagement: Increased patient engagement with teams, especially the CMA/LPN
- Quality of care: Measured by key Wisconsin Collaborative for Healthcare Quality metrics, 6.8% improvement from 2017 to 2018
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- Care team-centered outcomes
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- Electronic health record demands: Alleviation of electronic health record demands on clinicians while engaging with patients
- Physician satisfaction: Physician satisfaction improved as a result of this intervention, with 92% Providers reporting as “Satisfied” in 2017 St Norbert College survey
- RN satisfaction: Improved satisfaction for care team RNs, who transitioned from their traditional triage role to having a key role in direct patient care.
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- System outcomes:
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- Primary Care Provider retention: Improved retention and recruitment of primary care clinicians (of 6 Family Practitioners recently signed, most were only interested in working at Team-based Care transformed sites)
- Patient access: Patients are better able to access a planned care visit as soon as they thought they needed it (Prior to Team-based Care – 71%; 6 months post Team-based Care – 97%).
- Physical therapy (PT) use: Enhanced use of Physical Therapy in clinics with integrated PT
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- Economic return:
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- Value-based payments: Increased quality measures, resulting in more value-based payments
- Panel size: Increased panel size of clinicians, with average of 8% increase in individual clinician panel size between 2016 and 2018
- Patient visits: Increase in patient visits of 18% from 2016 to 2018
- Annual Medicare Wellness (AMW) visit completion: Increased revenue for completed AMW visits, with 73% completion rate for AMW visits in 2018 due to utilization of care team RN
- Decreased cost of care for Next Generation ACO patients ($27 reduction per member per month in 2018 vs 2017)
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Benefits
- The intervention improved outcomes for patients, care teams, and the healthcare organization, as above.
- The intervention resulted in the system’s increased preparedness for value-based payment models.
Unique Challenges
- There is ongoing analysis to ensure financial sustainability. Direct costs such as hiring of additional staff to provide electronic health record and documentation support are generally thought to be offset by an additional 2 visits per day.
- Indirect benefits of improved quality measures, decreased cost of care, increasing numbers of attributed patient, are among the things that need to be considered, especially as value based payments become more common.
- It was important to avoid expanding the pilot too quickly; the team spent almost 6 full months in prototype developing workflows and launching numerous PDSAs before starting to spread the program and the expansion to all 130 primary care teams took about 4 years.
- The workload on MAs and LPNs can be overwhelming as not all MAs or LPNs can make this transition so training must be thorough and thoughtful.
- As this model spreads, recruitment of adequate numbers of MAs and LPNs can be a challenge, which is one of the reasons this team used both MAs and LPNs in this role. Although staff turnover can present a challenge, as MAs and LPNs become more empowered in their enhanced roles, some will seek to advance their training and move on to other roles, such as the RN role. The team is working with Human Resources to increase compensation, and they are working with local technical colleges to increase supply and recruitment.
- RNs that are comfortable in their triage role may be uncomfortable in direct patient care.
- Physician buy-in and resistance to change has been an ongoing challenge for some sites.
- Change management and team culture need to be thoughtfully addressed.
Sources
- This primer was developed by CareZooming from in-depth analysis of research materials used with written permission of the author(s) and with significant input from Dr. James Jerzak for clarification. Authors were able to review the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
- American Medical Association, EHR In-Basket Restructuring for Improved Efficiency, in AMA STEPS Forward. 2017
- Bodenheimer, et.al. From Triple Aim to Quadruple Aim: Care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576
- Bodenheimer T, et al. RN role reimagined: how empowering registered nurses can improve primary care. California Health Care Foundation, 2015.
- Chung, S., et al., Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate.Health Aff (Millwood), 2015. 34(1): p. 11-20.
- Conducting Team Meetings in Green Bay, WI: A Case Study. AMA STEPS Forward – AMA Ed Hub. American Medical Association. June 1, 2015. Accessed March 17, 2019. Available at: https://edhub.ama-assn.org/steps-forward/module/2702517.
- Eden ,R. Maximizing your Medical Assistant’s Role. Fam Prac Manag, 2016. 23(3): p. 5-7. Jerzak, J. The Evolving Roles of MAs and Nurses in Team-Based Care. Fam Prac Manag 2019.
- Hopkins, K. and C.A. Sinsky, Team-based care: saving time and improving efficiency. Fam Pract Manag, 2014. 21(6): p. 23-9.
- Jerzak J. Radical Redesign: The Power of Team-Based Care. Ann Fam Med. 2017
May;15(3):281. - Lyon, C et al., A Team Based Care Model That Improves Job Satisfaction. Fam Prac Manag, 2018 25(2): p 6-11.
- Misra-Hebert, A.D., et al., Medical scribes: How do their notes stack up?J Fam Pract, 2016. 65(3): p. 155-9.
Innovators
- James Jerzak, MD
- Kathy Kerscher
Editors
- Jacqueline You, BA
Location
Green Bay, Wisconsin
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