From: Effective team-based primary care: observations from innovative practices
Innovation Area | Major Trends | Promising Innovations |
---|---|---|
Primary care team structure | • Providers and their panels are supported by a core team built around strong provider-MA partnerships. • Multi-provider core teams often include, RNs, and front desk staff. • Core team members including PCPs share offices and work spaces. • Extended practice teams often include RN care managers, behavioral health specialists, and pharmacists. | • Each PCP works with 2 MAs, who remain with each patient throughout their visit—doing intake, scribing for the PCP, and handling post-visit questions and issues. |
Enhanced role of medical assistants | • MAs review charts of scheduled patients and lead core team huddles to plan care. • MAs arrange or deliver most preventive care procedures. • MAs often involved in outreach to patients with care gaps or needing follow-up. • MAs are actively involved in Quality Improvement and play leadership roles. | • MAs with additional training in self-management support and diabetes care conduct individual and small group visits with diabetic patients. |
Roles of Registered Nurses | • Core team RNs provide follow-up care, skills training, and self-management support to chronically ill patients in nurse encounters or conjoint visits. • Team RNs use nurse visits and standing orders to manage common acute illnesses. • RN care managers work with small panels of high risk patients. | • RNs use delegated order sets to titrate medications for patients with common chronic conditions—e.g., warfarin, anti-hypertensive drugs. |
Layperson Patient Care Roles | • Laypersons help patients address needs for information, community resources, and coordination of their care. | • Laypersons trained in self-management counseling serve as health coaches. • Layperson EMR experts make changes to the EMR supportive of quality improvement. |
Managing Complex Illness | • RN Care Managers work with small panels of sicker patients, including those discharged from hospital. • Behavioral Health Specialists, other social workers, and lay care coordinators/community health workers address psychosocial needs. • Pharmacists provide Medication Therapy Management services to multi-problem patients. | • Weekly or bi-weekly case conferences convene multi-disciplinary clinic staff to discuss challenging patients and develop a comprehensive care plan, and review progress of previously discussed patients. |
Behavioral Health Integration | • Core team (MAs and RNs) involved in depression screening and follow-up. • On-site Behavioral Health Specialists facilitate warm handoffs and provide short-term therapy and crisis management. • Advice on psychotropic drugs is obtained from on-site or consulting Psychiatrists or Psychiatric NPs. | • Patients on chronic opioid therapy are tracked, asked to sign contracts, and offered in-clinic buprenorphine therapy if warranted. |
Clinic-Community Connections | • Practices hire staff from populations served by the clinic. • Designated practice team members help patients identify and access community services. • Practice actively cultivates partnerships with community organizations to address social and environmental issues. | • The practice works with other agencies in the community to address social determinants of health. |