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Practicing high-quality medicine requires collaboration and teamwork, but the first step is to build a talented staff
Care teams exist in nearly every medical office. But relatively few practices have organized and enhanced their care teams to increase efficiency and the likelihood that every patient will receive recommended care, says internist Charles Kilo, MD, who formerly led the Institute for Healthcare Improvement’s practice improvement initiative.
The biggest reason, Kilo says, is that value-based reimbursement has not fully taken hold, and a fee-for-service practice doesn’t need this kind of care team to succeed financially. But he and other experts maintain that, even under fee-for-service, care teams can improve practice efficiency, increase patient access and produce better outcomes.
How care teams work
Generally anchored by a physician, a care team includes registered nurses (RNs) and/or licensed practical nurses (LPNs), medical assistants (MAs) and front-office staff, such as receptionists and schedulers.
Some practices, mainly larger groups, have expanded their care teams to include behavioral health specialists, nutritionists, physical therapists and social workers.
RNs most often function as care managers for chronically ill patients. But care managers don’t have to be RNs, who are an expensive resource for small and medium-sized practices. Greenfield Health in Portland, Oregon, an 11-provider group where Kilo practices part-time (he’s also a consultant), has decided not to hire RNs because it can’t afford them, he says. Instead, the group has trained their MAs to do most of what RNs can do in ambulatory care.
A key characteristic of a care team is that its members are expected to work at the top of their licenses. In most cases this requires additional on-the-job training, but experts say working this way is good for staff morale.
“From the perspective of job satisfaction, the retention rate for advanced practice clinicians and other clinicians is a lot higher in an environment where they’re doing what they were trained to do, rather than just manage in-basket work all day,” says Krista Fakoory, MBA, senior manager with ECG Management Consultants in San Diego.
Another important feature of care teams is that members share responsibility for patient care. The physician still has the ultimate responsibility, but he or she delegates part of the care and the logistics that support it to other team members. This may include pre-visit care, such as medication reconciliation, chart reviews and lab result checks. During visits, it may include patient education, vaccinations and even prescription refills following clinical protocols.
In most practices doctors already delegate some care, notes practice management consultant Margalit Gur-Arie, a principal in the consulting firm BizMed. However, the extent to which physicians delegate tasks and set up organized processes for their staff varies widely, she says.
According to Gur-Arie, care teams are designed to “make sure that the patient doesn’t fall through the cracks. This is whole-person care, not just the 15-minute visit.”
In her view, care teams help practices run like businesses. Instead of physicians having to track down staff members to ask questions or assign tasks, those team members can take on a lot of routine tasks on their own, using standing protocols.
When physicians empower their staff to do more, the doctors reduce their own workload. “Doctors are essential resources, and we still have them doing way more work than they should be doing,” Kilo says. “We need to leverage the clinician’s time, so the clinician is doing higher level knowledge management and relationship management, and not so many of the tasks that the less expensive staff member can do.”
Jennifer Brull, MD, a primary care physician in Plainville, Kansas, agrees. “I tell my nurses, ‘If it’s within your license, you better be doing it, because I don’t have time.’”
Allowing healthcare professionals to practice at the top of their licenses is the key to effective care teams, says Jillian Schneider, MHA, manager of practice support for the American College of Physicians. For example, she says, a practice could have a standing order for nurses to give patients flu shots if they meet certain criteria. A nurse could vaccinate the patient and note it in the chart. “That’s one less thing the clinician has to do,” she says.
Nurses or MAs can also scan a patient’s medical history prior to a visit, checking to see whether their preventive and chronic care needs have been met. If there are care gaps, they inform the physician. They can also perform medication reconciliation ahead of the visit, saving the doctor time in the exam room. And they can check to see whether lab results are in for patients with chronic conditions.
Greenfield Health’s care teams perform all of these tasks before patient visits, Kilo says. In addition, they do non-visit related work, such as refilling prescriptions, calling patients who are due for recommended care, obtaining hospital discharge information and even providing non-visit care when appropriate.
In Oregon and most other states, Kilo says, MAs can handle some conditions on their own, including prescribing under standing orders if they follow protocols.
Kilo adds that a practice’s electronic health record (EHR) should allow care team members other than doctors to document their interactions with patients in the same areas of the chart that physicians use. Such EHRs improve efficiency and enable clinicians to identify which additions to the record were made by other team members.
Practices that use care teams regard good communication among members as critical to efficient practice operations.
“The daily huddle is a huge benefit for the practice,” says Fakoory. “You can lower your visit time because you’re not having those catch-up discussions in the hallway or when the patient is sitting in the room. That huddle can improve the patient experience and also the throughput of your clinic.”
Co-location is also an important success factor, Fakoory and Gur-Alie say. This can be a problem for doctors who expect to have their own offices, but they need not give them up if they have care teams.
Brull’s office, for instance, is two doors down from her practice’s care managers, and either she or they may pop in to each other’s offices to discuss a case. They also exchange internal electronic messages (commonly an internal message in the EHR). Brull sits just a few steps from one of the nurses who supports her in patient care, she says.
Practices that have adopted the patient-centered medical home model-the most likely places to find care teams-should have 4.25 full-time-equivalent (FTE) staff members to each FTE physician, according to a 2013 study in the American Journal of Managed Care. This ratio is 59% higher than the average primary care staffing ratio of 2.68 FTE staff per FTE physician, the researchers noted.
Kilo’s and Brull’s practices-both patient-centered medical homes-have ratios of between 4 and 4.5 FTE staff members per FTE provider. The ratio is higher than in traditional practices because their clinical and front office staff are required to do the additional work of population management.
By absorbing many tasks that typically fall to physicians, care teams can increase the capacity of practices to see patients and tend to their needs. Some primary care groups Fakoory has worked with have increased productive capacity by 10% to 20% the year after introducing care teams.
This additional capacity could be used to see more patients or to do more of what each patient needs. Increasing volume could help cover the extra overhead of care teams, but Gur-Alie strongly objects to this notion. “It’s not about seeing more patients. It’s about having more time with each one,” she says.
Kilo concurs. “If the patients feel they’re not being heard or you’re slamming through 25-30 patients a day, it’s good for your financial model, but it’s not so great for your patients.” Nevertheless, he says, it’s possible to use care teams to increase visits and revenue to some degree while also doing a better job for each patient.
Brull says she has seen year-over-year revenue increases since introducing care teams. But that isn’t necessarily because she sees more patients. The practice’s two care managers generate enough income to cover their own salaries just by doing annual Medicare wellness visits and meeting the requirements of Medicare’s Transitional Care and Chronic Care Management Programs. In addition, the group conducts a foot clinic for people with diabetes, arthritis and other issues, which covers her salary.
The financial message is that physicians in practices with care teams can sustain their net incomes while providing better care. “It’s the work that the population needs, delivered in a highly efficient and effective manner to get the best possible outcomes,” Kilo says.