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 (statistical significance [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.

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.

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.

Care Management For Patients With Type 2 Diabetes: The Roles Of Nurses, Pharmacists, And Social Workers.

Managing patients with type 2 diabetes takes time. Clinicians in primary care, where most diabetes visits take place, lack that time. Planned visits by diabetes care managers-nurses, pharmacists, social workers, and other team members-assist clinicians and are associated with improved glycemic control. Particularly effective is care management featuring nurses or pharmacists adjusting medications without prior physician approval. Care management programs need to pay close attention to inequities in diabetes care and outcomes. The widespread implementation of diabetes care management in primary care faces several barriers: lack of an adequate, diverse, trained care manager workforce; regulations limiting care managers' scope of practice; and financial models not supportive of care management. Wide-ranging policies are needed to address these barriers. In particular, payment reform is needed to stimulate the spread of diabetes care management: adding fee-for-service codes that adequately pay care managers for their work, adopting shared savings models that channel savings back to primary care, and increasing the percentage of health care spending dedicated to primary care. In this article we explore key questions around type 2 diabetes care management, review the published evidence, examine the barriers to its wider use, and describe policy solutions.

Process evaluation of a medical assistant health coaching intervention for type 2 diabetes in diverse primary care settings.

Team-based models that use medical assistants (MAs) to provide self-management support for adults with type 2 diabetes (T2D) have not been pragmatically tested in diverse samples. This cluster-randomized controlled trial compares MA health coaching with usual care in adults with T2D and poor clinical control ("MAC Trial"). The purpose was to conduct a multi-method process evaluation of the MAC Trial using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Reach was assessed by calculating the proportion of enrolled participants out of the eligible pool and examining representativeness of those enrolled. Key informant interviews documented adoption by MA Health Coaches. We examined implementation from the research and patient perspectives by evaluating protocol adherence and the Patient Perceptions of Chronic Illness Care (PACIC-SF) measure, respectively. Findings indicate that the MAC Trial was efficient and effective in reaching patients who were representative of the target population. The acceptance rate among those approached for health coaching was high (87%). Both MA Health Coaches reported high satisfaction with the program and high levels of confidence in their role. The intervention was well-implemented, as evidenced by the protocol adherence rate of 79%; however, statistically significant changes in PACIC-SF scores were not observed. Overall, if found to be effective in improving clinical and patient-reported outcomes, the MAC model holds potential for wider-scale implementation given its successful adoption and implementation and demonstrated ability to reach patients with poorly controlled T2D who are at-risk for diabetes complications in diverse primary care settings.

Integrating Physical Therapists Into Primary Care Within A Large Health Care System.

BACKGROUND: Bellin Health in Wisconsin has pioneered the colocation and integration of physical therapists into primary care pods. METHODS: This is an observational study based on one in-person visit and several interviews. RESULTS: For patients with musculoskeletal complaints, providers make warm handoffs to the physical therapist, who is a few steps away. The physical therapist performs most of the visit, providing diagnosis, treatment, and patient education. Research studies show that-compared with physician management-appropriate patients managed by physical therapists have better outcomes, lower costs, and higher patient satisfaction. In a fee-for-service environment, the business case for this innovation requires an increased number of follow-up referrals to the physical therapy department. In the Coronavirus disease 2019 (COVID-19) era, physical therapists can provide video visits with equal quality compared with in-person visits. CONCLUSION: The Bellin Health program is a blueprint for other primary care practices to integrate physical therapists into primary care teams.

Medical assistant health coaching ("MAC") for type 2 diabetes in diverse primary care settings: A pragmatic, cluster-randomized controlled trial protocol.

In the US, nearly 11% of adults were living with diagnosed diabetes in 2017, and significant type 2 diabetes (T2D) disparities are experienced by socioeconomically disadvantaged, racial/ethnic minority populations, including Hispanics. The standard 15-min primary care visit does not allow for the ongoing self-management support that is needed to meet the complex needs of individuals with diabetes. "Team-based" chronic care delivery is an alternative approach that supplements physician care with contact from allied health personnel in the primary care setting (e.g., medical assistants; MAs) who are specially trained to provide ongoing self-management support or "health coaching." While rigorous trials have shown MA health coaching to improve diabetes outcomes, less is known about if and how such a model can be integrated within real world, primary care clinic workflows. Medical Assistant Health Coaching for Type 2 Diabetes in Diverse Primary Care Settings - A Pragmatic, Cluster-Randomized Controlled Trial will address this gap. Specifically, this study compares MA health coaching versus usual care in improving diabetes clinical control among N = 600 at-risk adults with T2D, and is being conducted at four primary care clinics that are part of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in Southern California. Electronic medical records are used to identify eligible patients at both health systems, and to examine change in clinical control over one year in the overall sample. Changes in behavioral and psychosocial outcomes are being evaluated by telephone assessment in a subset (n = 300) of participants, and rigorous process and cost evaluations will assess potential for sustainability and scalability.

Coaching patients to be active, informed partners in their health.

In this issue, the article "A Physician Communication Coaching Program," by McDaniel and colleagues (see record 2020-40858-007), addresses this untenable situation through the coaching of physicians as part of continuing medical education. The coaching program hopes to explode the traditional paradigm of physician-patient interaction. An alternative paradigm is the philosophy of health coaching. While McDaniel et al. (2020) describe coaching physicians, the new paradigm involves coaching patients. Health coaching can be summed up in the adage: "Give a man a fish and you feed him for a day. Teach him how to fish and you feed him for a lifetime." Coaching is teaching "how to fish" by assisting patients to gain the knowledge, skills, and confidence to become informed, active participants in their care (Ghorob & Bodenheimer, 2013). Rather than telling patients what to do, coaching asks patients what they are willing and able to do to improve their health, meeting them where they are. Perhaps a patient with diabetes eats a pint of ice cream every night and cannot give it up. Rather than threatening, scolding, or imploring, physicians and other health personnel engage in a discussion of an action plan that the patient agrees to-perhaps eating only a half-pint of ice cream each night. Success with the realistic action plan breeds more success and eventually the ice cream becomes a rare treat. Randomized controlled trials demonstrate that this approach-compared with traditional care- significantly improves HbA1c levels in patients with diabetes (Thom et al., 2013; Willard-Grace et al., 2015). (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Outpatient Training Gap: A Pilot Study.

BACKGROUND AND OBJECTIVES: Most family medicine residency training takes place in hospitals, which is not reflective of the outpatient care practiced by most primary care clinicians. This pilot study is an initial exploration of family medicine residency directors' opinions regarding this outpatient training gap. METHODS: The authors surveyed 11 California family medicine residency program directors in 2017-2018 about factors that influence decisions regarding allocation of residents' inpatient and outpatient time. Nine of the 11 program directors agreed to be interviewed. We analyzed the interviews for common themes. RESULTS: The participating program directors were generally satisfied with inpatient and outpatient balance in their residents' schedules. Factors identified as promoting inpatient training included the need for resident staffing of hospital services, the educational value of inpatient rotations, and a lack of capacity in continuity clinics. From the program directors' perspective, residency funding played no direct role in curriculum planning. Program directors also felt that the ACGME requirements prescribing 1,650 continuity clinic visits throughout residency inhibited the development of creative outpatient training opportunities. CONCLUSIONS: Family medicine residency program directors participating in this exploratory study did not feel that their programs overly emphasized inpatient care and training.

Clinical Training Innovation for Prelicensure Graduate Nursing Students to Expand Roles in Primary Care.

BACKGROUND: With the aging population, the prevalence of chronic disease is increasing, requiring a team-based approach to care with registered nurses (RNs) playing a vital role. PROBLEM: Nursing education generally prioritizes acute care rather than ambulatory care; however, nursing students should also be prepared to adequately respond to the population needs for longitudinal chronic care management. APPROACH: To address the need for RNs to assume a role in chronic care management, a School of Nursing and Health Professions piloted a clinical option in which second-degree master of science in nursing students are prepared to function as health coaches on primary care teams at a local community health center. CONCLUSIONS: Reshifting the focus of nursing education to integrate primary care nursing, it is important to embed nursing students into primary care practices where they can learn about the longitudinal care of patients with chronic conditions.

Models of Faculty Involvement in Primary Care Residency Teaching Clinics.

Through site visits to 42 teaching clinics associated with family and internal medicine residency programs during 2013-2018, the authors observed a spectrum of faculty involvement. In this Perspective, they describe and share examples of the 3 faculty models they identified. Some programs have a small, focused faculty whose members spend at least 5 half-day sessions per week seeing patients or precepting residents in the clinic. Others have a large, dispersed faculty with many faculty physicians who spend 1 or 2 half-day sessions per week in the clinic. Some use a hybrid model with a small focused faculty group plus other faculty with little clinic time. The dispersed model was observed only in university-based residencies, and the focused faculty model was commonly seen in community-based residencies. While faculty in both settings must juggle multiple responsibilities, several studies have confirmed the value of having faculty committed to ambulatory care and teaching. In site visit interviews, clinic leaders indicated focused faculty play an important role in teaching clinics by championing clinic improvement, improving continuity of care, and enhancing the resident experience. Faculty physicians who spend substantial time in the clinic know the residents' patients, provide greater continuity of care, anchor clinic teams, and coordinate coverage for residents when they are on other rotations. Clinic and residency program leaders generally favored a shift toward a focused or hybrid model. The authors view the hybrid model as a practical way to balance the challenges of having a focused faculty with the multiple responsibilities facing university- and community-based faculty.

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.