COMPLEX CARE COORDINATION: DEVELOPMENT

OF A NEW ROLEPaige Hatcher, MD- Diplomate, ABFM- Preventive Medicine Resident, OHSU- MPH Candidate, PSU- Health Policy Fellow, OHA

Capacity

Average panel size as the population ages is estimated to increase to 2300 per PCP1.

This would require 7.4 hours a day to provide all their needed preventive care2 and 10.6 hours a day to manage their chronic conditions3.

15 minute FFS model

Share the CareTM

Thomas Bodenhemier, UCSF and California HealthCare Foundation

Based on model for caregiver support Shift from lone doctor with helpers

Physician has responsibility to make all the decisions and delegates tasks

Delegating tasks from doctor to team implies less work for doctor and more work for others

“We” paradigm means relocating responsibility. The panel is cared for by the team.

Ghoroh, A., & Bodenheimer, T. (2012). Share the Care: Building Teams in Primary Care Practices. Journal of the American Board of Family Medicine, 25(2), 143-145.

Share the CareTM

Co-location Team Goals Mapping Team Workflow Team Training, Meetings, and

Expectations Standing Orders

Key Elements of Team Building

Defined Goals and specific, measurable operational objectives

Clinical and Administrative systems Division of labor Training and Cross-training Communication Structures and Processes

Grumbach, K. (2004). Can Health Care Teams Improve Primary Care Practice? JAMA: The Journal of the American Medical Association, 291(10), 1246-1251. doi: 10.1001/jama.291.10.1246

Team Size and Composition

Optimal size 6-12 members to prevent increasing complexity and number of handoffs

Protected time required for all team members

Redefinition of existing roles, or creation of new ones, is critical

Stability of membership important Culture Changes/hierarchy

Low-Hanging Fruit

Procedures for providing prescription refillsEscobedo, J. (2002). Rethinking Refills. Family Practice Management, 9(9), 55-56.

Low-Hanging FruitPre-visit scrub for preventive care

Low-Hanging Fruit

Visual MeasuresThe Power of a Green Dot!

Huddles

General Rules• Meet prior to each session in a central

location• Limit the time to several minutes• Cover the same agenda every time

Stewart, E. E., & Johnson, B. C. (2007). Huddles: Improve Office Efficiency in Mere Minutes. Family Practice Management, 14(6), 27-29.

Huddles

What is needed for the day? Equipment, staff, extra time, etc.

Are there any obvious changes that need to be made to the schedule? (errors, rooming particular patients early or late, etc.)

Schedule issues for the day (meetings, breaks, other providers)

Records or lab results that are needed Identify schedule “bottlenecks”

Low-hanging Fruit

Procedures for informing patients of laboratory results

Team meetings led by non-physicians Conflict Resolution Training

Economic Impact

Cost per visit hasn’t decreased so far, but satisfaction and turnover have improved tremendously.

Physicians estimate that 50% of their time is spent on activities that could be performed by caregivers with far less training

Services provided outside the visit, and by non-physicians are harder to bill.

May increase volume and access and decrease costs to system at-large.

Bodenheimer, T. (2007, July). Building Teams in Primary Care: Lessons Learned (Rep. No. ISBN 1-933795-30-1).

Teamlet

Previsit Huddle Agenda Setting Medication Reconciliation Ordering Routing Services History Taking Visit Postvisit Soliciting Patient Concerns Closing the Loop Goal Setting Navigating the System

Bodenheimer, T., & Laing, B. Y. (2007). The Teamlet Model of Primary Care. The Annals of Family Medicine, 5(5), 457-461. doi: 10.1370/afm.731

Additional References

1. Alexander, G.C., J. Kurlander, M.K. Wynia. “Physicians in retainer (“concierge”) practice. A national survey of physician, patient, and practice characteristics.” Journal of General Internal Medicine 2005; 20:1079–83.

2. Yarnall, K.S., K.I. Pollak, T. Ostbye, K.M. Krause, J.L. Michener. “Primary care: is there enough time for prevention?” American Journal of Public Health 2003; 93:635–41.

3. Ostbye, T., K.S. Yarnal, K.M. Krause, K.I. Pollak, M. Gradison, J.L. Michener. “Is there time for management of patients with chronic diseases in primary care?” Annals of Family Medicine 2005; 3:209–14.