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Table 2 Primary Care Staff Organization, Roles and Activities in LEAP Practices

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.