The Association of Teamlets and Teams with Physician Burnout and Patient Outcomes.

BACKGROUND: Primary care "teamlets" in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team. OBJECTIVE: To determine the prevalence and performance of teamlets and teams. DESIGN: Cross-sectional observational study linking survey responses to Medicare claims. PARTICIPANTS: Six hundred eighty-eight general internists and family physicians. INTERVENTIONS: Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team). MAIN MEASURES: Descriptive: percentage of physicians in teamlet/team categories. OUTCOME MEASURES: physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending. KEY RESULTS: 77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries. CONCLUSIONS: Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.

Revitalizing Primary Care, Part 2: Hopes for the Future.

Part 1 of this essay argued that the root causes of primary care's problems lie in (1) the low percent of national health expenditures dedicated to primary care and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access. Part 2 explores policies and practice changes that could solve or mitigate these primary care problems.Initiatives attempting to improve primary care are discussed. Diffuse multi-component initiatives-patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and Comprehensive Primary Care Plus (CPC+)-have had limited success in addressing primary care's core problems. More focused initiatives-care management, open access, and telehealth-offer more promise.To truly revitalize primary care, 2 fundamental changes are needed: (1) a substantially greater percent of health expenditures dedicated to primary care, and (2) the building of powerful teams that add capacity to care for large panels while reducing burnout.Part 2 of the essay reviews 3 approaches to increasing primary care spending: state-level legislation, eliminating Medicare's disparity between primary care and procedural specialty reimbursement, and efforts by health systems. The final section of Part 2 addresses the building of powerful core and interprofessional teams.

Revitalizing Primary Care, Part 1: Root Causes of Primary Care's Problems.

This 2-part essay offers a discussion of the health of primary care in the United States. Part 1 argues that the root causes of primary care's problems are (1) the low percent of national health expenditures dedicated to primary care (primary care spending) and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access.Information used in this essay comes from my personal clinical and policy experience bolstered by summaries of evidence. The analysis leans heavily on my visits to dozens of practices and interviews with hundreds of clinicians, practice leaders, and practice staff.In 2016, the United States spent approximately 5.4% of total health expenditures on primary care, compared with an average among 22 Organization for Economic Co-operation and Development (OECD) countries of 7.8%. With average US primary care panel size around 2,000, it would take a clinician without an effective team 17 hours per day to provide good care to that panel. Low primary care spending and excessive panel sizes are related because most medical students avoid careers featuring underfunded practices with unsustainable work-life balance.Over the past 20 years, many initiatives-explored in Part 2 of this essay-have attempted to address these problems. Part 2 argues that to revitalize primary care, 2 fundamental changes are needed: (1) increased spending dedicated to primary care and (2) creating powerful teams that add capacity to care for large panels.

Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support.

Primary care teams are underpowered. Teams do not maximally redistribute team functions when clinicians are diverted from activities where they add the most value. This commentary describes "advanced team care with in-room support" as a way to "power-up" primary care teams. In this core team model, each clinician is paired with 2 or 3 highly trained medical assistants or nurses-care team coordinators (CTCs).Early evidence suggests that this model is more satisfying to clinicians, staff, and patients and is financially sustainable. Yet its spread has been hobbled by several misguided beliefs, such as that the physician can and should do most tasks, that technology replaces people, that health care is a transactional endeavor more than a therapeutic relationship, that regulation is the main lever by which to advance quality, and that the principal way to increase net revenue is to reduce overhead. A shift in mindset is needed to energize primary care.

Continuity and Access in the Era of Part-Time Practice.

The number of physicians seeing patients part time is growing, an evolution that challenges the primary care pillars of continuity and access. The growth of part-time practice is a response to burnout and to the pressures facing primary care physicians. Physicians who work fewer clinical hours and thereby reduce burnout are more satisfied with their careers, less likely to leave their jobs, and provide a better patient experience. Primary care practices can make a number of adjustments to optimize continuity and access in this era of part-time practice. Moreover, physicians who work fewer clinical hours are equally capable of fostering trusting relationships with patients as physicians seeing patients full time.

Improving Care Teams' Functioning: Recommendations from Team Science.

BACKGROUND: Team science has been applied to many sectors including health care. Yet there has been relatively little attention paid to the application of team science to developing and sustaining primary care teams. Application of team science to primary care requires adaptation of core team elements to different types of primary care teams. CORE TEAM ELEMENTS: Six elements of teams are particularly relevant to primary care: practice conditions that support or hinder effective teamwork; team cognition, including shared understanding of team goals, roles, and how members will work together as a team; leadership and coaching, including mutual feedback among members that promotes teamwork and moves the team closer to achieving its goals; cooperation supported by an emotionally safe climate that supports expression and resolution of conflict and builds team trust and cohesion; coordination, including adoption of processes that optimize efficient performance of interdependent activities among team members; and communication, particularly regular, recursive team cycles involving planning, action, and debriefing. These six core elements are adapted to three prototypical primary care teams: teamlets, health coaching, and complex care coordination. CONCLUSION: Implementation of effective team-based models in primary care requires adaptation of core team science elements coupled with relevant, practical training and organizational support, including adequate time to train, plan, and debrief. Training should be based on assessment of needs and tasks and the use of simulations and feedback, and it should extend to live action. Teamlets represent a potential launch point for team development and diffusion of teamwork principles within primary care practices.

Expanded roles of registered nurses in primary care delivery of the future.

BACKGROUND: Primary care in the United States is changing: practice size is increasing, there is a growing shortage of primary care practitioners, and there is a heightened prevalence of chronic disease. Given these trends, it is likely that registered nurses will become important members of the primary care team. PURPOSE: This paper explores the challenges and opportunities in primary care delivery in the 21st century and examines the likelihood of expanded roles for RNs to improve quality and add capacity to the primary care workforce. METHODS: We searched the peer-reviewed and gray literature for publications on primary care, primary care workforce projections, the future of nursing, and team-based care. DISCUSSION: The number of primary care physicians is expected to decrease in relation to the US population while the number of nurse practitioners is increasing, with the result that more and more patients will see nurse practitioners as their primary care practitioner. However, the primary care practitioner (physicians, nurse practitioners and physician assistants) to population ratio is dropping. As a result, other professionals will be needed to deliver primary care. As the nation's largest health profession, registered nurses (RNs) are in sufficient supply and have been shown to improve the care of patients with chronic conditions. It is likely that primary care practices of the future will include an enhanced role for RNs, particularly in chronic disease management. CONCLUSION: For RNs to assume an expanded role in primary care, several barriers need to be overcome: (1) the widespread introduction of payment reform that reimburses RNs to independently provide care for patients, and (2) nursing education reform that includes primary care nursing skills (3) scope of practice clarification for non-advance practice RNs working under standardized procedures.

Improving blood pressure control in general practice: A pilot study of the ImPress intervention.

BACKGROUND: Patients with hypertension and at high absolute cardiovascular disease risk are a priority group for improved blood pressure control. This study examined the impact of an intervention, primarily delivered by the general practice nurse, to identify, recall and manage patients with uncontrolled hypertension who are at high risk of cardiovascular disease. METHODS: A before-and-after pilot study with a six-month follow-up period was conducted in eight general practices in Sydney, Australia. RESULTS: From 507 patients identified, 82 (16.2%) attended an assessment visit, were eligible and provided baseline data. Of these, 55 (67.1%) completed the six-month follow-up. The mean decrease in blood pressure was 14.5 mmHg systolic and 7 mmHg diastolic. Significant decreases were also found in mean weight (1.3 kg), body mass index (0.5 kg/m">22) and waist circumference (1.9 cm). Adherence to blood pressure treatment, as measured by the Hill-Bone scale, significantly improved (P = 0.01) DISCUSSION: The results of this study justify further investigation in a randomised trial. If effective, the approach could alter the way hypertension care is organised and delivered in Australian general practice.

What Happens After Health Coaching? Observational Study 1 Year Following a Randomized Controlled Trial.

PURPOSE: Health coaching is effective for chronic disease self-management in the primary care safety-net setting, but little is known about the persistence of its benefits. We conducted an observational study evaluating the maintenance of improved cardiovascular risk factors following a health coaching intervention. METHODS: We performed a naturalistic follow-up to the Health Coaching in Primary Care Study, a 12-month randomized controlled trial (RCT) comparing health coaching to usual care for patients with uncontrolled diabetes, hypertension, or hyperlipidemia. Participants were followed up 24 months from RCT baseline. The primary outcome was the proportion at goal for at least 1 measure (hemoglobin A1c, systolic blood pressure, or LDL cholesterol) that had been above goal at enrollment; secondary outcomes included each individual clinical goal. Chi-square tests and paired t-tests compared dichotomous and continuous measures. RESULTS: 290 of 441 participants (65.8%) participated at both 12 and 24 months. The proportion of patients in the coaching arm of the RCT who achieved the primary outcome dropped only slightly from 47.1% at 12 to 45.9% at 24 months (P = .80). The proportion at goal for hemoglobin A1c dropped from 53.4% to 36.2% (P = .03). All other clinical metrics had small, nonsignificant changes between 12 and 24 months. CONCLUSIONS: Results support the conclusion that most improved clinical outcomes persisted 1 year after the completion of the health coaching intervention.

Are Low-Income Peer Health Coaches Able to Master and Utilize Evidence-Based Health Coaching?

PURPOSE: A randomized controlled trial found that patients with diabetes had lower HbA1c levels after 6 months of peer health coaching than patients who did not receive coaching. This paper explores whether the peer coaches in that trial, all low-income patients with diabetes, mastered and utilized an evidence-based health coaching training curriculum. The curriculum included 5 core features: ask-tell-ask, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling. METHODS: This paper includes the results of exams administered to trainees, exit surveys performed with peer coaches who completed the study and those who dropped out, observations of peer coaches meeting with patients, and analysis of in-depth interviews with peer coaches who completed the study. RESULTS: Of the 32 peer coach trainees who completed the training, 71.9% lacked a college degree; 25.0% did not graduate from high school. The 26 trainees who passed the exams attended 92.7% of training sessions compared with 80.6% for the 6 trainees who did not pass. Peer coaches who completed the study wanted to continue peer coaching work and had confidence in their abilities despite their not consistently employing the coaching techniques with their patients. Quotations describe coaches' perceptions of the training. CONCLUSIONS: Of low-income patients with diabetes who completed the evidenced-based health coaching training, 81% passed written and oral exams and became effective peer health coaches, although they did not consistently use the techniques taught.

Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial.

PURPOSE: Health coaching by medical assistants could be a financially viable model for providing self-management support in primary care if its effectiveness were demonstrated. We investigated whether in-clinic health coaching by medical assistants improves control of cardiovascular and metabolic risk factors when compared with usual care. METHODS: We conducted a 12-month randomized controlled trial of 441 patients at 2 safety net primary care clinics in San Francisco, California. The primary outcome was a composite measure of being at or below goal at 12 months for at least 1 of 3 uncontrolled conditions at baseline as defined by hemoglobin A1c, systolic blood pressure, and low-density lipoprotein (LDL) cholesterol. Secondary outcomes were meeting all 3 goals and meeting individual goals. Data were analyzed using χ(2) tests and linear regression models. RESULTS: Participants in the coaching arm were more likely to achieve both the primary composite measure of 1 of the clinical goals (46.4% vs 34.3%, P = .02) and the secondary composite measure of reaching all clinical goals (34.0% vs 24.7%, P = .05). Almost twice as many coached patients achieved the hemoglobin A1c goal (48.6% vs 27.6%, P = .01). At the larger study site, coached patients were more likely to achieve the LDL cholesterol goal (41.8% vs 25.4%, P = .04). The proportion of patients meeting the systolic blood pressure goal did not differ significantly. CONCLUSIONS: Medical assistants serving as in-clinic health coaches improved control of hemoglobin A1c and LDL levels, but not blood pressure, compared with usual care. Our results highlight the need to understand the relationship between patients' clinical conditions, interventions, and the contextual features of implementation.

From triple to quadruple aim: care of the patient requires care of the provider.

The Triple Aim-enhancing patient experience, improving population health, and reducing costs-is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.

The 10 building blocks of high-performing primary care.

Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements-engaged leadership, data-driven improvement, empanelment, and team-based care-that assist the implementation of the other 6 building blocks-patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.

High-Performing Teamlets in Primary Care: A Qualitative Comparative Analysis.

PURPOSE: In efforts to improve patient care, collaborative approaches to care have been highlighted. The teamlet model is one such approach, in which a primary care clinician works consistently with the same clinical staff member. The purpose of this study is to identify the characteristics of high-performing primary care teamlets, defined as teamlets with low rates of ambulatory care sensitive emergency department (ACSED) visits and ambulatory care sensitive hospital admissions (ACSAs). METHODS: Twenty-six individual qualitative interviews were performed with physicians and their teamlet staff member across 13 teamlets. Potentially important characteristics related to high-performing primary care teamlets were identified, calibrated, and analyzed using qualitative comparative analysis (QCA). RESULTS: Key characteristics identified by the QCA that were often present in teamlets with low rates of ACSED visits and, to a lesser extent, ACSAs were staff proactiveness in anticipating physician needs and physician-reported trust in their staff member. CONCLUSION: This study suggests that physician trust in their staff and proactiveness of staff in anticipating physician needs are important in promoting high-performing teamlets in primary care. Additional studies are indicated to further explore the relationship between these characteristics and high-performing teamlets, and to identify other characteristics that may be important.

Medical Assistant Health Coaching for Type 2 Diabetes in Primary Care: Results From a Pragmatic Cluster Randomized Controlled Trial.

OBJECTIVE: This cluster (clinic-level) randomized controlled trial (RCT) compared medical assistant (MA) health coaching (MAC) with usual care (UC) among at-risk adults with type 2 diabetes in two diverse real-world primary care environments: a federally qualified health center (FQHC; Neighborhood Healthcare) and a large nonprofit private insurance-based health system (Scripps Health). RESEARCH DESIGN AND METHODS: A total of 600 adults with type 2 diabetes who met one or more of the following criteria in the last 90 days were enrolled: HbA1c ≥8% and/or LDL cholesterol ≥100 mg/dL and/or systolic blood pressure (SBP) ≥140 mmHg. Participants at MAC clinics received in-person and telephone self-management support from a specially trained MA health coach for 12 months. Electronic medical records were used to examine clinical outcomes in the overall sample. Behavioral and psychosocial outcomes were evaluated in a subsample (n = 300). RESULTS: All clinical outcomes improved significantly over 1 year in the overall sample (P < 0.001). The reduction in HbA1c was significantly greater in the MAC versus UC group (unstandardized Binteraction = -0.06; P = 0.002). A significant time by group by site interaction also showed that MAC resulted in greater improvements in LDL cholesterol than UC at Neighborhood Healthcare relative to Scripps Health (Binteraction = -1.78 vs. 1.49; P < 0.05). No other statistically significant effects were observed. CONCLUSIONS: This was the first large-scale pragmatic RCT supporting the real-world effectiveness of MAC for type 2 diabetes in U.S. primary care settings. Findings suggest that this team-based approach may be particularly effective in improving diabetes outcomes in FQHC settings.

Storylines of family medicine XII: family medicine and the healthcare system.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XII: Family medicine and the future of the healthcare system', authors address the following themes: 'Leadership in family medicine', 'Becoming an academic family physician', 'Advocare-our call to act', 'The paradox of primary care and three simple rules', 'The quadruple aim-melding the patient and the health system', 'Fit-for-purpose medical workforce', 'Universal healthcare-coverage for all', 'The futures of family medicine' and 'The 100th essay.' May readers of these essays feel empowered to be part of family medicine's exciting future.

Peer coaching to improve diabetes self-management: which patients benefit most?

BACKGROUND: Peer health coaching is an effective method of enhancing self-management support in patients with diabetes. It is unclear whether peer health coaching is equally beneficial to all patients with poor glycemic control, or is most effective for subgroups of patients. OBJECTIVE: To examine whether the effect of peer health coaching on hemoglobin A1c (A1c) is modified by characteristics that are known to be associated with diabetes control. DESIGN: Sub-group analyses of randomized control trial. PARTICIPANTS: Two hundred and ninety nine patients with diabetes receiving care in public health clinics who participated in a randomized controlled trial of peer health coaches. MAIN MEASURES: We examined whether the association between study group and change in A1c was modified by differences in patients' demographic, behavioral or psychosocial characteristics. Analyses were adjusted for co-variables associated with change in A1c. KEY RESULTS: The effect of coaching on patient A1c was modified by patients' level of self-management and degree of medication adherence as baseline (p=.02, and p=.03 respectively in adjusted models). For participants with "low" self-management (one standard deviation below the mean score), the usual care group experienced a slight increase in A1c (0.3 %), while the health coaching group experienced a decrease (-0.9 %). For participants with "high" self-management (one standard deviation above the mean score), both groups experienced a similar decrease in A1c (usual care group: -1.0 %; health coaching group: -1.1 %). Participants with "low" medication adherence in the usual care group experienced an increase in A1c (0.5 %), while the health coaching group experienced a decrease (-0.8 %). Participants with "high" medication adherence experienced similar decreases (usual care group: -1.1 %; health coaching group: -1.3 %). CONCLUSION: Peer health coaching had a larger effect on lowering A1c in patients with low levels of medication adherence and self-management support than in patients with higher levels. Peer health coaching interventions may be most effective if targeted to high-risk patients with diabetes with poor glycemic control and with poor self-management and medication adherence.