TEAM APPROACH/CARE COORDINATION
Featuring North Shore Physicians Group
This is one in a series of stories about strategies primary care practices are using to increase patient engagement. MHQP is in a unique position to learn about structural programs and innovative practices that help empower patients to be active in their own care, as we have recently completed a first-of-its-kind statewide study of patient engagement activities in primary care practices in Massachusetts with the support of CRICO.
One of the common ways practices enhance patient engagement is through a team approach to care coordination.
In recent years, pressures have mounted on primary care providers to deliver high-quality care in less time to an ever-growing panel of patients. As one strategy to end this unsustainable cycle, many primary care practices have sought to spread the primary care provider’s traditional work load among a team of providers, each of whom is encouraged and empowered to “work to the top of their license.”
Distributing the workload reduces the burden on the PCP and elevates other members of the team. In this way, practices can get today’s work done today and staff and providers are able to achieve better work-life balance.
One organization that has achieved great success through a team approach is North Shore Physicians Group, a multi-specialty group practice affiliated with North Shore Medical Center and Partners HealthCare, with 320+ providers and 23 locations throughout Boston's North Shore. Lindsay Gainer, RN, MSN, Senior Executive Director of Innovation, discusses their transformation in this area:
“Over the past several years, we’ve focused intensely on reducing the burden of work for the providers. In 2007, when we were just beginning our journey around lean transformation and thinking about patient-centered medical home, our providers were drowning. There was a study in JAMA in 2009 that said that if one PCP were to manage an average panel of patients and provide every bit of care that every one of those patients needed, it would take something like 21-22 hours per day, which is obviously unsustainable. That felt like our experience at the time. Our goal over the last 5-7 years has been to level-load that work across the whole practice team and to engage and allow each member of the team to work to the top of their license or their scope of practice – and make sure everyone feels like an empowered and valued member of the team. If you spread out the work, you can get all of today’s work done today, patients are going to have their needs met, and our staff and providers are able to have work-life balance, which helps address provider burnout issues.
One key to patient engagement for us is leveraging each of our different team members. We have certain guiding principles for what care teams look like, but each practice team looks a little bit different. We try to be flexible to make the team the most appropriate skill mix for the unique patient population in that practice.
Alongside the physicians and NPs, we rely heavily on medical assistants – they are the backbone of our practices. They are fundamental to our whole care model and elevating their role has been a huge part of our transformation. One of the roles they play is as a flow manager. Our MAs work in a one-to-one ratio each day with our providers and they sit side-by-side in what we call a flow station. For the most part, we don’t have separate provider office spaces anymore; it’s pretty much all shared, communal workspace. We’ve created a strong dyad between the medical assistant and the provider. A big part of the medical assistant’s job is set up for the providers and a lot of that is done through standard work. In this model, medical assistants are able work to the top of their scope and nothing should go to the provider unless the MA has touched it first and done everything they possibly can do to try to solve a patient issue or to complete a form as much as possible. Then, the provider can come out from seeing a patient, do their notes, do their billing, and do a few simple tasks – sign a form, complete a refill, perhaps read a consult note – before they move on to the next patient. That is how we have accomplished getting away from batching huge piles of work at the end of the day and get our providers and staff home on time.
The MAs also do a lot around population management. In the rooming process, part of their standard work is to look at overdue tests. If the patient is due for a colonoscopy, for example, it’s up to the MA to start that conversation. They don’t go into all the details about the risks – that would be up to the provider – but they’re starting the conversation and that elevates them in the patient’s eyes as an important member of the care team. The MA is also doing health coaching, both during the rooming process and between visits. Another part of their standard work for rooming is to ask the patient what their health goals are – every visit, every time, including sick visits. They typically follow-up on that goal at the next visit. If they saw a diabetic patient three months ago and that patient said, “I want to start walking three times per week,” then the MA will ask them next time, “How’s the walking going?” By starting the conversation, they are teeing things up before the provider comes in the room.
Elevating the MA’s role and giving them confidence in that role didn’t happen overnight. We do a lot of training with our medical assistants. We’ve developed a four-day intensive clinical training that builds on their post-secondary training. The training is mostly about the “Why” – why do we do things and it builds their critical thinking and helps them be a more valuable member of the team. It’s been very well received by our staff and our providers.
We’ve also completely changed the role of nursing in our practices, from a very traditional office nurse – where we believe many nurses were working far below their scope of practice and doing things that well-trained medical assistants can do – to an elevated role of nurse care managers to help with complex patients that have multiple needs, often more than can be addressed in a 20-40 minute visit every 3 months.
Social work and embedded behavioral health are also hugely important additions to our practices. We used to rely exclusively on our wonderful community mental health resources for behavioral health needs, but there was limited access and there was a lot of stigma. By having those services embedded in our practices as part of our team, we’ve really been able to move the needle and help those patients.
With nursing and social work, we’ve really tried to focus on matching the right patient with the right primary care manager. The PCP is always the leader of the team, but there are a lot of complex issues at play. So, what we’ve tried to do is what we call skill-task alignment. If it’s primarily a mental health issue, a social worker is usually going to be their primary care manager, working shoulder-to-shoulder with the PCP to come up with a care plan for the patient and doing a lot of the between-visit touches with that patient. If it’s medical frailty or complexity, it’s usually going to be a nurse case manager. And if it’s social instability or lack of social support, it’s going to be a social worker or maybe a community resource specialist. We’re very collaborative in our practices, but we do try to have someone on point, depending on the patient’s needs.
And then there’s the newest role on our team, Population Health Coordinators, which is something centrally funded through Partners. They sit offline, and do a lot of virtual work with our registries in EPIC. They do a lot of cleaning of the data, but they’re also doing automated reminders for patients that have care gaps. By doing this, we’re able to sort down to the patients that we need to escalate back to the care team – those patients that have numerous care gaps or have gone a very long time without care or have an A1c that’s wildly out of control. They feed that information to the care team – because if they’re not coming in to see us, we may not know that they have these care gaps. It’s a very new program for us. It’s something that’s been tested at the very large academic medical centers downtown, but we’re one of the first community groups to try this with Partners, so we’re very excited about it. It’s another way of trying to relieve the burden of work from the people in the office, not having to comb through manual lists or dig through those registries. That’s not really a value-added task for physicians and MAs and being able to take that offline is a huge benefit.
The keys to our success are about not just asking people to do more as a team, but trying to remove the waste and the burden of work in what they’re doing – so every person on the team is doing a manageable amount of work every day. Our people are happier, which has led to many positive outcomes. We’ve had a huge increase in our professional engagement and teamwork. We’ve maximized operational efficiency. We’ve had reduced turnover and increased provider satisfaction. And all of that dovetails with our overall patient experience scores, which have gone up year-after-year, particularly on experience with adult behavioral health and patient engagement.”