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

LEAP PROJECT: BACKGROUND & METHODS

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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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31 LEAP Sites

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

KEY FINDINGS: OVERVIEW

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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.

Outcomes

Function

Roles

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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The functions associated with high quality, comprehensive primary care

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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KEY FINDINGS: BUILDING A TEAM CULTURE

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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

Systems to support a team culture

Meetings QI

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?

THE TEAM GUIDE

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www.improvingprimarycare.org

Information Organized in 18 Modules under “Build the Team and “Do the Work”

Information Organized in 18 Modules under “Build the Team and “Do the Work”

Over 300 resources available across topic areas

March

16,

2018

Each Module Accompanied by an Assessment

Examples of Tools: #1

Examples of Tools: #2

The Team Guide: Beyond LEAP

www.improvingprimarycare.org

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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THANK YOU!

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