Primary Care Patients' and Staff's Perceptions of Self-Rooming as Alternative to Waiting Rooms.

PURPOSE: Most patients are escorted to exam rooms (escorted rooming) although patients directing themselves to their exam room (self-rooming) saves patient and staff time while increasing patient satisfaction. This study assesses patient and staff perceptions after pragmatic implementation of self-rooming. METHODS: In October-December 2020, we surveyed patients and staff in 25 primary care clinics after our institution expanded self-rooming from 4 specially built clinics during the COVID-19 pandemic. Semi-structured surveys asked about rooming process used, rooming process preferred, and perceptions of self-rooming compared with escorted rooming. RESULTS: Most patients (n = 1,561) preferred self-rooming (86%), especially among patients aged <65 years and in family medicine clinics. Few patients felt less welcomed (10.6%), less cared about (6.8%), more isolated (15.6%), more lost/confused (7.6%), or more frustrated (3.2%) with self-rooming compared with escorted rooming. Early-adopter clinics that implemented self-rooming ≤2016 had even lower rates of patients feeling more isolated, lost/confused, or frustrated with self-rooming compared with escorted rooming.Over one-half of staff (n = 241; 180 clinical, 61 nonclinical) preferred self-rooming (59%) and thought most patients liked self-rooming (65.8%), especially among clinical staff and in early adopter clinics (≤2016). Few staff reported worse waiting times for patients (12.4%), medical assistants (MAs) (15.9%), and clinicians (16.4%) or worse crowding in waiting areas (1.7%) and hallways (10.1%). Unlike patient-reported confusion (7.6%), most staff thought self-rooming led to more patient confusion (63.8%), except in early-adopter clinics (44.4%). CONCLUSIONS: Self-rooming is a patient-centered innovation that is also acceptable to staff. We demonstrated that pragmatic implementation is feasible across primary care without expensive technology or specially designed buildings.

The Impact of a Primary Care Education Program Regarding Cancer Survivorship Care Plans: Results from an Engineering, Primary Care, and Oncology Collaborative for Survivorship Health.

Survivorship care plans (SCPs) have been recommended as tools to improve care coordination and outcomes for cancer survivors. SCPs are increasingly being provided to survivors and their primary care providers. However, most primary care providers remain unaware of SCPs, limiting their potential benefit. Best practices for educating primary care providers regarding SCP existence and content are needed. We developed an education program to inform primary care providers of the existence, content, and potential uses for SCPs. The education program consisted of a 15-min presentation highlighting SCP basics presented at mandatory primary care faculty meetings. An anonymous survey was electronically administered via email (n = 287 addresses) to evaluate experience with and basic knowledge of SCPs pre- and post-education. A total of 101 primary care advanced practice providers (APPs) and physicians (35% response rate) completed the baseline survey with only 23% reporting prior receipt of a SCP. Only 9% could identify the SCP location within the electronic health record (EHR). Following the education program, primary care physicians and APPs demonstrated a significant improvement in SCP knowledge, including improvement in their ability to locate one within the EHR (9 vs 59%, p < 0.0001). A brief educational program containing information about SCP existence, content, and location in the EHR increased primary care physician and APP knowledge in these areas, which are prerequisites for using SCP in clinical practice.

Cancer Survivorship Care Plan Utilization and Impact on Clinical Decision-Making at Point-of-Care Visits with Primary Care: Results from an Engineering, Primary Care, and Oncology Collaborative for Survivorship Health.

Every cancer survivor and his/her primary care provider should receive an individualized survivorship care plan (SCP) following curative treatment. Little is known regarding point-of-care utilization at primary care visits. We assessed SCP utilization in the clinical context of primary care visits. Primary care physicians and advanced practice providers (APPs) who had seen survivors following provision of an SCP were identified. Eligible primary care physicians and APPs were sent an online survey, evaluating SCP utilization and influence on decision-making at the point-of-care, accompanied by copies of the survivor's SCP and the clinic note. Eighty-eight primary care physicians and APPs were surveyed November 2016, with 40 (45%) responding. Most respondents (60%) reported discussing cancer or related issues during the visit. Information needed included treatment (66%) and follow-up visits, and the cancer team was responsible for (58%) vs primary care (58%). Respondents acquired this information by asking the patient (79%), checking oncology notes (75%), the SCP (17%), or online resources (8%). Barriers to SCP use included being unaware of the SCP (73%), difficulty locating it (30%), and finding needed information faster via another mechanism (15%). Despite largely not using the SCP for the visit (90%), most respondents (61%) believed one would be quite or very helpful for future visits. Most primary care visits included discussion of cancer or cancer-related issues. SCPs may provide the information necessary to deliver optimal survivor care but efforts are needed to reduce barriers and design SCPs for primary care use.

Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach.

BACKGROUND: Health systems in the United States are increasingly required to become leaders in quality to compete successfully in a value-conscious purchasing market. Doing so involves developing effective clinical teams using approaches like the clinical microsystems framework. However, there has been limited assessment of this approach within United States primary care settings. METHODS: This paper describes the implementation, mixed-methods evaluation results, and lessons learned from instituting a Microsystems approach across 6 years with 58 primary care teams at a large Midwestern academic health care system. The evaluation consisted of a longitudinal survey augmented by interviews and focus groups. Structured facilitated longitudinal discussions with leadership captured ongoing lessons learned. Quantitative analysis employed ordinal logistic regression and compared aggregate responses at 6-months and 12-months to those at the baseline period. Qualitative analysis used an immersion/crystallization approach. RESULTS: Survey results (N = 204) indicated improved perceptions of: organizational support, team effectiveness and cohesion, meeting and quality improvement skills, and team communication. Thematic challenges from the qualitative data included: lack of time and coverage for participation, need for technical/technology support, perceived devaluation of improvement work, difficulty aggregating or spreading learnings, tensions between team and clinic level change, a part-time workforce, team instability and difficulties incorporating a data driven improvement approach. CONCLUSIONS: These findings suggest that a microsystems approach is valuable for building team relationships and quality improvement skills but is challenged in a large, diverse academic primary care context. They additionally suggest that primary care transformation will require purposeful changes implemented across the micro to macro-level including but not only focused on quality improvement training for microsystem teams.

Development and Impact of a Novel Academic Primary Care Compensation Model.

BACKGROUND: Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits. OBJECTIVE: To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes. DESIGN: Observational study. PARTICIPANTS: Forty-seven general internists who practice in affiliated academic and community clinics. MAIN MEASURES: Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity. KEY RESULTS: The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %. CONCLUSIONS: An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population.

Reduction in Medication Refill Encounters Through Primary Care Redesign Workflow Changes.

With a goal of improving efficiency and reducing workload outside of visits, we sought to examine a primary care redesign process aimed at reducing refill requests made outside of office visits. Data on the number of refill encounters per panel member were collected at 17 clinics before, during, and after the implementation of a redesign process. There was an initial reduction in the number of medication refill encounters, and the rate of refill encounters continued to decline following implementation. Variation across clinic contexts suggests that redesign processes may need to be tailored for different settings to optimize effectiveness.

Does a Change in Physician Compensation Lead to Changes in Care Delivery in Family Medicine Clinics?

BACKGROUND AND OBJECTIVES: Many highly capitated systems still pay physicians based on relative value units (RVU), which may lead to excessive office visits. We reviewed electronic health records from the family medicine clinic panel members of 97 physicians and 42 residents to determine if a change from RVUs to panel-based compensation influenced care delivery as defined by the number of office visits and telephone contacts per panel member per month. METHODS: A retrospective analysis of the electronic health records of patients seen in 4 residency training clinics, 10 community clinics, and 4 regional clinics was conducted. We assessed face-to-face care delivery and telephone call volume for the clinics individually and for the clinics pooled by clinic type from 1 year before to at least 1 year after the change. RESULTS: Change in physician compensation was not found to have an effect on office visits or telephone calls per panel member per month when pooled by clinic categories. Some significant effects were seen in individual clinics without any clear patterns by clinic size or type. CONCLUSIONS: Change in physician compensation was not a key driver of care delivery in family medicine clinics. Understanding changes in care delivery may require looking at a broad array of system, physician, and patient factors.

Influence of Environmental Design on Team Interactions Across Three Family Medicine Clinics: Perceptions of Communication, Efficiency, and Privacy.

OBJECTIVE: In this study, we explored how two different primary care clinic physical layouts (onstage/offstage and pod-based [PB] designs) influenced pre- and postvisit team experiences and perceptions. BACKGROUND: Protocols encourage healthcare team communication before and after primary care visits to support better patient care. Physical clinic environments may influence these behaviors, but limited research has been performed. METHOD: We conducted observations, three interviews with clinic managers, and six focus groups with 21 providers and staff at three family medicine teaching clinics. Observational data were captured through field notes and spaghetti diagrams. Interviews and focus groups were recorded, transcribed, and analyzed using a grounded theory-based approach to understand how aspects of the clinic environment affected communication, efficiency, and privacy. RESULTS: Variations in communication styles and trade-offs between patient contact and privacy emerged as differences. In the onstage/offstage design, colocated teams had increased verbal communication but perceived being isolated from other clinic teams. In contrast, teams in PB clinics communicated with other clinic teams but had more informal patient contact within care-team stations that imposed privacy risk. CONCLUSIONS: Primary care clinic design appears to alter provider-team and patient-provider communication and flow. Organizations should consider aligning environmental design with desired interaction patterns when building new primary care clinics.

A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large US Multidisciplinary Group Practice.

BACKGROUND: Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice. METHODS: A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed. RESULTS: After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients. CONCLUSIONS: The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.

Vasectomy Practice Patterns Among Family Medicine Physicians and Compliance With the American Urological Association 2012 Vasectomy Guidelines.

OBJECTIVE: To survey urologists and family medicine physicians (FMPs) within a single institution to determine current vasectomy practice patterns and determine compliance with 2012 American Urological Association (AUA) vasectomy guidelines. METHODS: In 2016, a single-institution survey was conducted to understand the vasectomy practice patterns among urologists and nonurologists. The survey questions and 3 clinical scenarios were designed based on the 2012 AUA vasectomy guidelines. Results of the survey were compiled between urologists and nonurologists and then compared with the guideline recommendations. RESULTS: A total of 23 FMPs and 6 urologists responded. Fewer prevasectomy counseling topics were discussed by FMPs compared with urologists. A variety of vasectomy techniques were used among FMPs. Vas deferens segments were more likely to be sent for histology by FMPs than urologists (65% vs 17%, P = .02). FMPs were more likely to send postvasectomy semen analyses earlier than urologists (P = .02) and more likely to send multiple postvasectomy semen analyses (P = .006) before forgoing alternative contraceptive methods. Regarding the clinical scenario questions, FMPs were more likely to answer discordantly from guideline recommendations compared with urologists. CONCLUSION: Significant vasectomy practice pattern heterogeneity still exists among nonurologists surveyed within our institution. The 2012 AUA vasectomy guidelines have yet to be broadly implemented within nonurology practices. Further studies are warranted to investigate national trends in nonurologist vasectomy practice patterns and determine how the guidelines can be better implemented in nonurologic practices.

Building the learning health system: Describing an organizational infrastructure to support continuous learning.

INTRODUCTION: Academic health centers are reorganizing in response to dramatic changes in the health-care environment. To improve value, they and other health systems must become a learning health system, specifically one that has the capacity to understand performance across the continuum of care and use that information to achieve continuous improvements in efficiency and effectiveness. While learning health system concepts have been well described, the practical steps to create such a system are not well defined. Establishing the necessary infrastructure is particularly challenging at academic health centers due to their tripartite missions and complex organizational structures. METHODS: Using an evidence-based framework, this article describes a series of organizational-level interventions implemented at an academic health center to create the structures and processes to support the functions of a learning health system. RESULTS: Following implementation of changes from 2008 to 2013, system-level performance improved in multiple domains: patient satisfaction, population health screenings, improvement education, and patient engagement. CONCLUSIONS: This experience can be applied to health systems that wrestle with making system-level change when existing cultures, structures, and processes vary. Using an evidence -based framework is useful when developing the structures and processes that support the functions of a learning health system.

Family Physician Clinical Compensation in an Academic Environment: Moving Away From the Relative Value Unit.

BACKGROUND AND OBJECTIVES: Primary care physician compensation structures have remained largely volume-based, lagging behind changes in reimbursement that increasingly include population approaches such as capitation, bundled payments, and care management fees. We describe a population health-based physician compensation plan developed for two departmental family medicine faculty groups (residency teaching clinic faculty and community clinic faculty) along with outcomes before and after the plan's implementation. METHODS: An observational study was conducted. A pre-post email survey assessed satisfaction with the plan, salary, and salary equity. Physician retention, panel size, and relative value unit (RVU) productivity metrics also were assessed before and after the plan's implementation. RESULTS: Before implementation of the new plan, 18% of residency faculty and 33% of community faculty were satisfied or very satisfied with compensation structure. After implementation, those numbers rose to 47% for residency physicians and 74% for community physicians. Satisfaction with the amount of compensation also rose from 33% to 68% for residency faculty and from 26% to 87% for community faculty. For both groups, panel size per clinical full-time equivalent increased, and RVUs moved closer to national benchmarks. RVUs decreased for residency faculty and increased for community faculty. CONCLUSIONS: Aligning a compensation plan with population health delivery by moving rewards away from RVU productivity and toward panel management resulted in improved physician satisfaction and retention, as well as larger panel sizes. RVU changes were less predictable. Physician compensation is an important component of care model redesign that emphasizes population health.

Across the divide: "Primary care departments working together to redesign care to achieve the Triple Aim".

BACKGROUND: Primary care is considered the foundation of an effective health care system. However, primary care departments at academic health centers have numerous challenges to overcome when trying to achieve the Triple Aim. METHODS: As part of an organizational initiative to redesign primary care at a large academic health center, departments of internal medicine, general pediatrics and adolescent medicine, and family medicine worked together to comprehensively redesign primary care. This article describes the process of aligning these three primary care departments: defining panel size, developing a common primary care job description, redesigning the primary care compensation plan, redesigning the care model, and developing standardized staffing. RESULTS: Prior to the initiative, the rate of patient satisfaction was 85%, anticoagulation measurement 65%, pneumococcal vaccination 85%, breast cancer screening 79%, and colorectal cancer screening 69%. These rates all improved to 87%, 75%, 88%, 80%, and 80% respectively. Themes around key challenges to departmental integration are identified: (1) implementing effective communication strategies; (2) addressing specialty differences in primary care delivery; (3) working within resource limitations; and (4) developing long-term sustainability. CONCLUSIONS: Primary care in this large academic health center was transformed through developing a united primary care leadership team that bridged individual departments to create and adopt a common vision and solutions to shared problems. Our collaboration has achieved improvements across patient satisfaction, clinical safety metrics, and publicly-reported preventive care outcomes. IMPLICATIONS: The description of this experience may be useful for other academic health centers or other non-integrated delivery systems undertaking primary care practice transformation.

Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study.

BACKGROUND: Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care. OBJECTIVE: To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes. METHODS: A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling. PARTICIPANTS: 155 health professionals at 6 U.S. primary care clinics participated from May through December 2013. RESULTS: Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (rate ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (ß=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes. CONCLUSIONS: Primary care teams which relied on frequent daily face-to-face communication among more team members, and had a single RN communicating patient care information to the PCP, had greater shared team vision, better patient outcomes, and lower medical costs for their diabetes patient panels.

Are waiting rooms Passé? A pilot study of patient self-rooming.

Timeliness of care after patients arrive at the primary care office has received little examination. At 2 community family medicine clinics, an intervention was piloted replacing traditional waits in the waiting room with patients directing themselves to their examination rooms. We examined patient acceptability, experience of care, and staff time and cost savings before and after the intervention. Most patients (95%) preferred rooming themselves. Patient satisfaction remained high. Staff time and cost savings were achieved at both sites. Our findings suggest that self-rooming is desirable to patients. Others interested in redirecting staff time toward value-added patient care tasks should consider trialing this intervention.