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High Functioning Primary Care Teams: Learning from Effective Ambulatory Practices (LEAP)
Integrated Health Care 2018Michael Parchman, MD, MPHDirector MacColl Center for Health Care InnovationKaiser Permanente of Washington Health Research Institute
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The Wonderful KPWHRI LEAP Team
• Sarah McDonald
• Brian Austin
• Paula Blasi
• Adele Clark
• Katie Coleman
• DeAnn Cromp
• Dona Cutsogeorge
• Nora Henrikson
• Sylvia Hoffmeyer
• Leslie Jaurequi
• Salene Jones
• Caitlin Morrison
• Michael Parchman
• Melissa Parson
• James Ralston
• Julie Reardon
• Judith Schaefer
• Leah Tuzzio
• Nicole Van Borkulo
• Callie Walsh-Bailey
• Ed Wagner
Co-Director Margaret Flinter, Community Health Center, Inc. CT
Project Officer Maryjoan Ladden, Robert Wood Johnson Foundation
Session Objectives
At the conclusion of this session the participant will be able to:
– Describe the typical structure of high-functioning primary care teams
– Explain how expanded roles and core functions interact to achieve exemplary outcomes in a high-functioning primary care team
– Discuss three strategies used to develop and sustain high-functioning teams in primary care
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Presentation Outline
Tour of the Team Guide
Project Background & Methods
Key Findings: Overview
Key Findings: Building Team Culture
Dissemination & Future Plans
Overall Project goals:
Study 30 innovative primary care practices that can serve as models for improving efficiency and quality of the healthcare workforce.
Summarize what we learn in a web-based Guide.
Disseminate the Guide to practices involved in practice transformation, and evaluate.
Site Selection
NAC selected 30
Requested data on quality of care (70)
National Advisory Committee (NAC) members & staff rated (154)
Telephone interviews & 2-page summary (154)
Nomination by national primary care experts (435)
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Overview of Site Visit Activities
• 3 consecutive days
• 3 site visitors-qualitative, clinical, research
assistant
• Collected the following data:
o Interview key leaders
o Clinic tour and EMR Demonstration
o Individual interviews with up to 5 staff members
o Formal staff and patient shadowing
o Online staff survey
o Photo documentation by staff
o Collect documents, tools
o Observe meetings/activities related to innovations
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Summary of Data
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94 observation notes from site visitors
30 group leadership interviews
157 individual interviews with staff members
70 staff members shadowed
122 patients shadowed
Over 500 tools and 200 photos
1000+ bagels purchased
Team Structure:Major Findings From Site Visits
March
16,
2018
Medical assistants, receptionists, and
lay-persons play key patient care roles .
Roles are expanded. All staff work at the
top of their license and skillsets.
All core teams supported by RN care
managers, behavioral health specialists,
pharmacists, etc.
Providers and their panels supported by
Core teams consisting of MAs, front desk,
and others.
Primary Care Team Structure
CentCoreTeam
Provider
-MA
Teamlet
Provider
-MA
Teamlet
Provider
-MA
Teamlet
Extended Care Team
• Receptionist
• Team RN
• Health Coach
• Panel Manager
• RN Care Managers
• Lay Caregivers
• Pharmacists
• Behavioral Health
Specialists
• Administrative Staff
LEAP Core Team Composition
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1 Primary Care
Provider*
n = 6
2-3 Primary Care
Providers*
n = 15
4+ Primary Care
Providers*
n = 9
All Practices
n = 30
Medical Assistants** 6 (100%) 15 (100%) 9 (100%) 30 (100%)
Registered Nurses 1 (17%) 6 (40%) 7 (78%) 14 (47%)
Licensed Practical
Nurses (LPNs)
0 4 (27%) 0 4 (13%)
Front Desk Staff 1 (17%) 8 (53%) 1 (11%) 10 (33%)
Behavioral Health 0 3 (20%) 2 (22%) 5 (17%)
Health Coach 1 (17%) 1 (7%) 2 (22%) 4 (13%)
Lay Care Coordinator 0 1 (7%) 1 (11%) 2 (7%)
Social Worker 0 0 1 (11%) 1 (3%)
Roles: Maximizing contributions to patient care
MA
• Fixed MA-provider-panel relationship was most common and critical to build trust with PCPs
• MA relationships with patients encouraged
• Plan care, collect patient information, provide most preventive services
RNs
• Team RNs play key roles in managing chronically ill patients and common acute illnesses including shared/independent RN patient visits
• RN care managers support complex patients and those in transition
Lay persons
• Integrated into teams and encouraged to build relationships with patients
• SDOH, health coaching and administrative tasks
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Roles: Maximizing staff contributions to patient care
Clinical Pharmacists
• key members of the care team through warm handoffs, team huddles, and routine medication review with patients.
The Behavioral Health Specialist
• Co-located with or near the primary care team.
• Available for warm hand-offs.
• Focused on short-term therapy.
• Helpful in referring people with more severe, long-term mental health issues for more specialized care.
• Able to efficiently communicate with other members of the primary care team.
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Quality Improvement Observations
Local engagement/ ownership of QI even in
large multi-site orgs.
Key quality related data regularly reviewed,
discussed, and displayed
Involvement of all team members in QI
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intentional about building a team culture and supporting teamwork
Strategies: Team supports StrategiesChange the culture Mission, vision, values around
teams/teamwork
Create team identities and workspace
Formal and informal teambuilding
Systems to support team culture
Regular communication Quality improvement
Cultivate the workforce Role development
Hiring
Training
Career Ladders
Changing to a team culture
Mission, vision, values around
teams
Create team identities and
workspace
Formal and informal team-
building
Cultivating the workforce
• Hire the right people
• Interview as a teamHiring
• Internal training curriculum
• Orientation to the teamTraining
• Create career ladders
• Personal growth and leadership development
Career Ladders
Opportunities and challenges
Provider and staff retention
Training the current and future workforce
How pay for all this?
Dissemination
• Effective Team-based Primary Care (Launch Paper)
• The Emerging Primary Care Workforce
• Primary Care Clinic Re-Design for Prescription Opioid Management
• Registered Nurses in Primary Care: Emerging Roles…
• Developing Emerging Leaders to Support Team-Based Primary Care
Papers-Published
• Building a team culture
• Team Structures
• Behavioral Health Integration
• Complex Care Management
• Patient Perspectives on Team Based Care
• Literature Review-Evidence for Team-based Care
Papers-
In Progress
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Implications for KPW
KPW actively working on designing and building primary care teams
LEAP findings influenced Advancing Primary Care
KPWHRI’s Learning Health System is drawing on LEAP learnings
Team guide training offered to David McCulloch’s Quality Champions
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