• Expanding the Primary Care Team

    Lola Butcher Nov 04, 2014

    Enterprising health systems and medical clinics are creating new ways to help primary care patients improve their health status without adding burdens to the physician workload.  

    The widespread consensus that the United States faces a growing physician shortage is getting new consideration since the Institute of Medicine proposed an overhaul for physician training (Graduate Medical Education that Meets the Nation’s Health Needs, 2014). The proposal’s authors say the country suffers from a geographic mismatch between physicians and patients and that we have a disproportionate number of specialists compared to primary care physicians. But they are not convinced that America has too few physicians.

    That view stands in sharp contrast to the Association of American Medical Colleges, which forecasts a shortage of 45,000 primary care physicians and 46,000 surgeons and specialists by 2020. The Academy’s assessment is based on the challenges that everyone agrees on: millions of Americans are expected to gain insurance through the Affordable Care Act, 80 million aging baby boomers will require more medical attention, and the obesity and diabetes epidemics are eating up more healthcare resources.

    Those numbers also assume that medicine will continue to be practiced in the way it has in the past—despite evidence to the contrary. Across the country, health systems and physician practices are expanding access to healthcare services in ways that do not require a physician’s immediate presence. The resourcefulness is wide-ranging: telehealth applications (see feature on mhealth), new types of healthcare workers, reorganized responsibilities, and new formats for delivering care.

    The opportunities are so widespread that some observers say the term “physician shortage”—particularly as it applies to primary care—is a misnomer. Thomas Bodenheimer, MD, adjunct professor at the University of California-San Francisco, and Mark Smith, president and CEO of the California HealthCare Foundation, frame the issue as a “demand-capacity mismatch.”

    “Primary care practices could greatly increase their capacity to meet patient demand if they reallocate clinical responsibilities—with the help of current technologies—to non-physician team members and to patients themselves,” they wrote (“Primary Care: Proposed Solutions to the Physician Shortage Without Training More Physicians,” Health Affairs, November 2013, vol. 32, no. 11, pp. 1881-1886).

    In the following case studies, health systems and medical clinics share their experiences with innovative approaches to meeting healthcare needs:

    Team-Based Care

    Oregon’s Mosaic Medical, a federally qualified health center with five primary care clinics, began practicing team-based care in 2010 when it adopted the patient- centered medical home model. Team-based care replaces the traditional model of primary care, in which the physician is responsible for all care delivery, with a model in which a team of professionals and paraprofessionals work together to meet patient needs.

    There are three team models: top-of-license, care coordinator, and enhanced traditional (see the exhibit below). Mosaic Medical uses a top-of-the license approach to team-based care, which means that providers—physicians, nurse practitioners, or physician assistants—serve as team leaders while each clinical team member provides direct patient care, as appropriate.


    “By allowing the physicians and other team members to work at the top of their licenses, we are working toward maximum productivity and the best care for the patient,” says Elaine Knobbs, director of programs and development. “But this is an evolution, and we’re not there yet.”

    While Mosaic Medical has not quantified an increase in productivity, researchers studying this model at other locations have documented dramatic results (Goldberg, D.G., et al., “Team-Based Care: A Critical Element of Primary Care Practice Transformation,” Population Health Management, June 2013, vol. 16, no. 3, pp. 150-156):

    • Physicians see 35 to 40 patients a day, up from 22 to 23.
    • Per-physician gross revenues increased by $180,000 per year.
    • Quality improved, as measured by blood pressure and cholesterol control.

    Working as teamlets. Each of the Mosaic Medical teams contain a registered nurse (RN) care coordinator, a community health worker, and a behavioral health consultant. Each team also has a care assistant who handles clinical and administrative tasks, such as reviewing charts, processing pharmacy refill requests, and helping to coordinate a patient’s care among team members.

    Each team works with about four “teamlets,” which are comprised of one provider and one medical assistant (see the exhibit below). While each teamlet has its own panel of patients, the team shares responsibility for all of the teamlets’ patients. “It’s a culture change because it has been in our societal expectation that the provider handles all the questions and carries the load, and other people support the provider,” Knobbs says.


    Shifting responsibilities requires new ways of working together. At the Mosaic Medical Redmond clinic, the medical director has trained medical assistants to perform foot exams for patients with diabetes. That transfer of responsibility requires a provider to train the medical assistants, providers to trust the medical assistants, and medical assistants to feel confident in their abilities.

    Meanwhile, RN care coordinators are primarily responsible for providing education, case management, and follow-up care to children and adults with chronic conditions. High-risk patients with complex conditions have direct access to an RN care coordinator, who works with other team members—for example, a behavioral health consultant—to help the patients manage their illnesses.

    Changing approaches and workflows. Mosaic Medical’s first step to team-based care was the adoption of an electronic health record (EHR) that gives all team members access to the same information. After that, Mosaic Medical began trying to institutionalize team-based care, which required hiring new staff and converting some existing positions to new roles. “Team development just does not happen by putting people together and calling them a team,” Knobbs says. “It requires communication and role clarity.”

    Workflows were changed. For example, clinical support staff are working on using guidelines and standing orders to provide care for patients with chronic conditions, reducing the need for physician visits. In addition, team members received training specifically on how to improve communication to work together most effectively.

    Each provider/medical assistant teamlet meets daily to preview the day’s appointments, bringing in other team members as needed. Beyond that, each team meets weekly for a quality huddle to discuss practice improvement and practice metrics. Each team uses the quality huddle to work on specific goals of their own choosing, such as decreasing patient no-show rates or increasing the percentage of patients receiving tobacco cessation counseling.

    Leading from the top. As a community health center, Mosaic Medical had many elements of team-based care in place, but the culture shift needed to change the delivery model cannot be overstated. “One of the biggest lessons learned is the intentionality and time needed to do team-based care well,” Knobbs says.

    Making the time for training and process changes is difficult because the volume of patients is increasing so rapidly. Mosaic’s total patient population has ballooned to nearly 27,000—an increase of nearly 28 percent—since January 1 because of Medicaid expansion and patients acquiring insurance via the exchanges. But that growth makes training and process changes all the more imperative. “It requires ongoing meetings to watch our progress and learn from it—and to be nimble about trying new innovations with team-based care,” Knobbs says.


    Mosaic Medical’s executive team and senior leaders meet twice a month to spend an hour talking specifically about the team model. That group is using a guide from the California HealthCare Foundation, called The Building Blocks of High-Performing Primary Care: Lessons from the Field, to guide the teams on the changes they need to make.

    “We continually remind ourselves to stay at the 30,000-foot level and let the teams figure out the operations,” Knobbs says. “But, step by step, we have been identifying the gaps we still have and thinking through how to tackle them, while giving each clinic some guardrails around how to operationalize these concepts.”

    Nurse-Managed Clinics

    When Glide Health Services started serving patients in an underserved area of San Francisco in 1997, it was one of relatively few nurse-managed health clinics in the country. Today, nearly 300 nurse-managed clinics are in operation, and advocates believe such clinics can play an important role in expanding healthcare access.

    “We are in a good place right now because a need is often the impetus for trying new things,” says Patricia Dennehy, DNP, the director of Glide Health Services from 1999 until late last year.

    The clinic’s nurse practitioners, assisted by an RN and students from various disciplines, serve more than 3,000 patients each year. Those patients have high rates of poverty, homelessness, mental illness, and substance abuse. The care team provides primary, urgent, and preventive care, including HIV prevention and chronic disease management. A pharmacist helps patients manage complex medication regimens, and a part-time internist provides consults. (California regulations require collaboration with a physician.)

    Managing behavioral and social issues. Like other nurse-managed clinics, Glide Health uses a nursing model of care that focuses on addressing the root causes of health problems and working to prevent them. “Part of the nursing model is to look at the whole person— not just the fact that you have hypertension or you have diabetes, but what are your other comorbid risk factors?” Dennehy says. “What are your social determinants that are affecting your health, and how do we make sure that they’re being addressed at the same time as the illness? How do we teach you to use your resources wisely so that you’re feeding your kids food that won’t make them sick?”

    Shortly after Glide Health Services opened, Dennehy added behavioral health services. About 40 percent of patients receive behavioral health services from social workers and a psychiatrist who work at the clinic one day a week.

    “You can’t really address someone’s primary care issues if they have a full-blown mental health or substance abuse problem that isn’t being addressed at the same time,” she says. “It was much easier to offer these services in the same place.”

    However, because of the chronic shortage of mental health providers for uninsured patients, Glide Health risked being overrun with referrals from across the city. The clinic established a policy that all behavioral health patients had to first be enrolled as primary care patients. “We eventually had to make that a requirement because we didn’t want to become an exclusive mental health clinic,” she says. “We wanted to be a clinic that addressed the mental health needs of our primary care patients.”

    Funding a still controversial model. Growth of nurse-managed clinics has been limited by regulations in many states. While 18 states and the District of Columbia allow nurse practitioners to diagnose and treat patients and prescribe medications without physician oversight, the other 32 states require physician involvement to diagnose and treat patients, to prescribe medications, or both (“Health Policy Brief: Nurse Practitioners and Primary Care,” Health Affairs, updated May 15, 2012).

    The American Medical Association and other physician groups are opposed to expanding the scope of practice for nurse practitioners, saying that patients’ health may be put at risk because nurse practitioners have less education than physicians. On the other side of the debate, the federal government is an advocate for nurse-managed clinics. A demonstration project involving 10 nurse-managed clinics is currently under way, courtesy of funding through the Affordable Care Act.

    Glide Health, a federally qualified health center, was established with funding from the Glide Foundation, a social service agency, the University of California San Francisco School of Nursing, and St. Francis Memorial Hospital. Because it focuses on poor and homeless patients, federal and philanthropic grants have been an important funding source over the years.

    Addressing a new challenge. Most nurse-managed clinics are independent or affiliates of a nursing school, and many of them focus on uninsured patients who have no other access to health care. Ironically, as those patients gain coverage through the expansion of Medicaid, the business model for those clinics becomes more difficult. Many states use Medicaid managed care, which requires the clinics to verify eligibility and handle utilization management and other time-consuming administrative responsibilities.

    “Right now, the business aspects of this are challenging for smaller practices,” says Dennehy who is now Western Region director for the National Nursing Center Consortium. “We are looking at working with some larger healthcare organizations that can afford the administrative overhead.”


    Group Visits

    A neurosurgeon at North Shore Medical Center in Salem, Mass., introduced group visits for patients with back pain as a way to better address patient needs and shorten the waiting time for appointments. “The patients have a similar problem—lower back pain and disk disease,” says Stephanie Eisenstat, MD, director of the Shared Medical Care Program, Massachusetts General Hospital. “They are usually a homogenous group, and he was able to double his productivity and address his patients’ needs simply by bringing them in through the group.”

    Despite that compelling example, group visits do not always increase an individual physician’s productivity, says Eisenstat. Even when they do, that might not be the best reason for using a group visit model. “There isn’t a one-size-fits-all way of thinking about group visits,” she says. “The important thing is to have your goals very clear in mind, as well as a very clear plan of how this service integrates into the total picture of care.”

    If a group visit is established specifically to increase access, like the North Shore back pain group, it is likely to increase physician productivity. But some group visit programs are designed to improve patient education— for example, to help patients with diabetes understand their disease—while others seek to motivate patients to change their behaviors. Those group visit programs are expected to reduce the demand for healthcare services over the long term, but they do not necessarily increase physician productivity in the short term.

    Learning from other patients. Eisenstat, a primary care practitioner at Women’s Health Associates, started working with a psychologist to offer group visits about seven years ago because many of her patients with diabetes and hypertension were not meeting their health targets, such as losing weight or controlling blood sugar levels.

    She thought the traditional 15-minute office visit was not effectively supporting them so they could succeed with self-management and medication adherence at home.

    In a group visit—sometimes called a shared medical appointment—a group of patients meets with a team that usually includes a physician or nurse practitioner and possibly a nurse or behavioral specialist (such as a psychologist or social worker) for a session that lasts 1.5 to 2.5 hours. That allows time for medical review, education for the group as a whole, and a facilitated discussion in which patients learn from one another.

    “In the traditional shared medical visit model, the doctor addresses the patients one by one, with patients sitting in a semi-circle, talking to each patient about his or her particular issues,” Eisenstat says. “As they go through the issues, more general conversations come up, maybe around exercise or meal planning or something more generic that is of interest and importance to all the patients.”

    Reducing physician visits. Group visits may not increase the productivity of physicians who treat patients with complex, chronic conditions. However, if the group visits achieve their primary goal of improving patients’ health status, they can have the secondary benefit of ensuring the appropriate utilization of services and reducing demand for physician services.

    “The education component of group visits could play a huge role in managing healthcare costs as patients learn to self manage their care, which results in fewer visits to the physician and emergency department,” says Evan Porter, director of finance and special projects at Massachusetts General. “This, over time, will be a huge factor in helping to deal with the physician shortage.”

    Addressing billing issues. A common barrier to group visits is lack of confidence in how to properly bill because there are no nationally accepted standards for coding and billing for group visits. The American Academy of Family Practitioners received guidance from Medicare that the appropriate evaluation and management codes that apply to face-to-face physician visits also apply to group visits. Among private insurers, there are no standard billing guidelines for physicians conducting group visits.

    As fee-for-service contracts are supplanted by capitation and other emerging payment systems, group visits can be a cost-effective way to improve the health of a subset of populations, Eisenstat says.

    Creating and sustaining group visits requires team care, engaged providers and patients, a patient recruitment strategy, careful planning by the clinical team running the visits, and a willingness to try a different approach with patients. Eisenstat and her colleagues developed a handbook called Putting Group Visits into Practice, which is available at massgeneral.org/stoecklecenter. They also started a “Group-on-Groups” forum to allow clinicians interested in group visits to start groups and share information about what has worked—and not worked—in their individual experience with group visits.



    If patients take better care of themselves, fewer physicians will be needed. That thinking prompted a physician Arthur Garson, MD, MPH, chairman of the Grand-Aides Foundation, to develop the concept for a new kind of non-licensed healthcare worker, called a grand-aide. These workers—generally certified nurse assistants with additional training specific to the patient population they work with—serve as a go-between who links patients with the physicians and nurses responsible for their care.

    Whether they are working with primary care patients, new mothers, patients requiring palliative care, or those with chronic illnesses, grand-aides provide the intense interaction that keep patients on course—and keep licensed clinicians apprised of their status. The idea stemmed from a long-ago conversation that Garson—now the director of the Health Policy Institute at Texas Medical Center—had with a colleague: “He said ‘You know a fair number of my patients could be taken care of by a good grandparent.’”

    That comment came back to him years later when Garson chaired a national workforce commission. “The first actual talk that I ever gave about this was entitled ‘The Grandparent Corps,’ and it was in Beijing because I was thinking about ‘barefoot doctors’—training laypeople to do things because there just aren’t enough physicians to do everything,” he says. “It turns out that in the U.S., it is illegal to require the aides to be grandparents so we changed the name to grand-aides to keep to the idea that these workers no matter how old—30, 40, 60—have the characteristics of a good grandparent.”

    In the last four years, the concept has grown to nearly 50 healthcare lay-person programs that are active or under development around the world, including at least three dozen in the United States.

    Visiting patients after discharge. The services provided by a typical non-licensed healthcare worker vary, depending on the population served and the goals of the program. At the Advanced Heart Failure Center in the University of Virginia Health System, the grand-aides (who are full- or part-time employees of the health system) are assigned to patients being discharged from the hospital after a heart failure diagnosis by nurse practitioner-supervisor Craig Thomas. They visit the patient at home on each of the first five days after discharge, with decreasing visits over the next weeks. After that, the aides call or visit as needed until the patient no longer needs the intense support.

    Unlike community health workers, who often provide social service support, translation services, or transportation, grand-aides focus primarily on a patient’s medical situation, although they are trained to address social issues as well. The healthcare laypersons—paid about $25,000 per year, plus benefits if they work full-time—complete a formal training program that includes education about the patient population they will serve. But they do not provide direct patient care.

    “This is not a patient care program. This is a patient empowerment and family empowerment program that gets people to take better care of themselves,” Garson says.

    At each visit, the grand-aide collects vital signs, including weight, and uses a series of yes/no questions to collect information about a patient’s situation. The first questions look for urgent symptoms that require immediate attention—“Does the patient have a smothering feeling, cannot speak in full sentences, breathlessness?”—that would prompt the worker to call the supervising nurse practitioner. The remaining questions seek information about less serious symptoms and determine if the patient is following the prescribed diet and taking medications properly.

    All information is recorded and relayed to a nurse or nurse practitioner who supervises the grand-aides. At each visit, the supervisor has a brief telemedicine conference with the patient and family. With heart failure patients, this includes observing the patients’ breathing. “The grand-aides don’t make decisions. They are the eyes and ears of the rest of the care team,” Garson says.

    Estimating the ROI. The University of Virginia program started in January 2013. For the 110 patients served in the first 16 months, all-cause readmissions were 58 percent below matched heart failure patients for the previous year without grand-aides. “Physicians have grown to understand and appreciate the program benefits, and I now get cold calls asking if this program can help with a particular patient,” Thomas says.

    The program’s cost, including grand-aides, supervisor, supplies, travel expenses, and technology, is approximately $60,000 per grand-aide per year. A grand-aide can care for 50 to 75 patients (Thomas, C., “A Home Visit Program by Non-Licensed Personnel Can Make a Difference in Heart Failure,” Journal of Hospital Administration, 2014, vol. 3, no. 3, pp. 1-6).

    The ROI for a grand-aide program depends on an institution’s individual circumstances. For hospitals trying to avoid Medicare penalties for high 30-day readmission rates, a grand-aide program can be worth millions of dollars in potentially lost revenue, Garson says.

    Recruiting patients at the right time. Introducing the concept of a grand-aide and winning a patient’s acceptance to have this person come to his or her home frequently for a few weeks requires a thoughtful approach. In the University of Virginia heart failure program, Thomas is responsible for recruiting patients to participate, and he has found the best time is at the start of discharge planning.

    “If I met them to discuss this program too soon, they were so focused on each breath they could not think past it,” he says. “If I waited until the day of discharge, they felt too healthy and that they didn’t need assistance.”

    Engaging in tough love. Several personal attributes are essential for the health workers, Thomas says. Although they are in close contact with him throughout the day to discuss their patients, they work from home and must be able to work autonomously, without frequent reminders about what they are supposed to do. They must be tech-savvy because they use iPads at each home visit to look up protocols and document details of the visit in the EHR. “The technology system is the core of what makes the visits quick and the information available to providers,” Thomas says.

    Beyond that, however, the grand-aide must be capable of “tough love,” the right balance of caring and forcefulness to help patients follow the medical plan. “It is not easy being in the home and having the courage to be firm in reinforcing the recommendations,” he says. “But if that person is a push-over, he or she will not be respected and won’t be effective.”

    In other words, that person needs to be like a good grandparent.

    Many Solutions, None Easy

    None of the strategies described in this article, by themselves, will fully meet the growing demand for healthcare services in the future, but each may be part of the solution. “Any strategy that can help to improve patient access and provide more intensive patient education to help patients manage their illnesses needs to be tried,” Evan says.

    Lola Butcher is a freelance writer and editor based in Missouri and a contributing writer to Leadership.

    Quoted in this article:
    Patricia Dennehy, DNP, is western regional director, National Nursing Centers Consortium, San Francisco.
    Stephanie Eisenstat, MD, is director, Shared Medical Care Program, Massachusetts General Hospital, Boston.
    Arthur Garson Jr., MD, is director, Health Policy Institute, Texas Medical Center, Houston.
    Elaine Knobbs is director of programs and development, Mosaic Medical Inc., Bend, Ore.
    S. Craig Thomas is nurse practitioner, University of Virginia Health System, Charlottesville, Va.

    Access related article: Sidebar: Basic Format of a Group Visit in 10 Steps


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