Team Configurations, Efficiency, and Family Physician Burnout.

INTRODUCTION: The delivery of team-based care relies on team structure and teamwork. Little is known about the landscape of team configurations in family medicine practices in the United States. Teamwork between diverse team members likely impacts both performance and physician well-being. We examined team configuration and teamwork and whether they are associated with family physician (FP) well-being. METHODS: We used data from practice demographic questionnaires completed by FPs who registered for the American Board of Family Medicine Family Medicine Certification Examination in 2017 and 2018. We grouped 14 types of health care professionals into medical assistant (MA)/nurse, nurse practitioner (NP)/physician assistant (PA), and specialist, and we characterized 3 common team configurations. We used FPs' subjective ratings to measure perceived teamwork efficiency and a validated single-item measure to identify FPs who were burned out. RESULTS: Among 2575 FPs in our sample, 22% worked collaboratively with MA/nurse only; 40% with MA/nurse and NP/PA or specialist; and 38% with MA/nurse, NP/PA, and specialist. The distribution of perceived teamwork efficiency was not statistically different across team configurations. In teams with greater perceived teamwork efficiency, FPs were less likely to be burned out. For FPs working with expansive teams, optimal perceived teamwork efficiency was associated with significantly reduced odds of burnout after controlling for practice and physician characteristics. CONCLUSION: Most FPs practice in multidisciplinary teams. Regardless of the team structure, FPs who perceived their teams as having greater efficiency were less likely to be burned out. We found that optimal perceived teamwork efficiency was associated with significantly reduced odds of burnout for FPs in all types of team configurations. Improving teamwork efficiency may be an effective strategy for practice organizations to support not only team functioning but also physician well-being.

Increasing Chlamydia Testing Rates via Targeted Outreach.

BACKGROUND AND OBJECTIVES: Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infection (STI) in the United States. Annual chlamydia screening of asymptomatic, sexually active women age 16 to 24 years and in older women who are at increased risk for infection is recommended. This study built on prior work in which our university-based family medicine clinic implemented quality improvement (QI) interventions in 2016 and 2017 to increase our chlamydia screening rate. Our primary aim in the current study was to increase the screening rate by 10%. Our secondary aim was to determine the number of patient contacts that yielded maximum test rates. METHODS: For the most recent QI cycle, we conducted a prospective cohort study from December 2017 through March 2018. Using the FOCUS-PDSA model, a resident-led, interdisciplinary QI team developed the aims and implemented an intervention to streamline patient outreach. We also retrospectively analyzed data from the previous QI cycle to determine the number of tests obtained after each patient contact. RESULTS: Chlamydia testing increased from 54% to 56.3% between December 2017 and March 2018. The majority of tests were completed by four patient contacts; additional contacts yielded few additional tests. CONCLUSIONS: Persistent outreach increases chlamydia screening rates. This QI project could be replicated in other clinical settings to improve the screening of chlamydia or other diseases.

Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

The cost of sustaining a patient-centered medical home: experience from 2 states.

PURPOSE: As medical practices transform to patient-centered medical homes (PCMHs), it is important to identify the ongoing costs of maintaining these "advanced primary care" functions. A key required input is personnel effort. This study's objective was to assess direct personnel costs to practices associated with the staffing necessary to deliver PCMH functions as outlined in the National Committee for Quality Assurance Standards. METHODS: We developed a PCMH cost dimensions tool to assess costs associated with activities uniquely required to maintain PCMH functions. We interviewed practice managers, nurse supervisors, and medical directors in 20 varied primary care practices in 2 states, guided by the tool. Outcome measures included categories of staff used to perform various PCMH functions, time and personnel costs, and whether practices were delivering PCMH functions. RESULTS: Costs per full-time equivalent primary care clinician associated with PCMH functions varied across practices with an average of $7,691 per month in Utah practices and $9,658 in Colorado practices. PCMH incremental costs per encounter were $32.71 in Utah and $36.68 in Colorado. The average estimated cost per member per month for an assumed panel of 2,000 patients was $3.85 in Utah and $4.83 in Colorado. CONCLUSIONS: Identifying costs of maintaining PCMH functions will contribute to effective payment reform and to sustainability of transformation. Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff, or both. Adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions.

Impact of an integrated transition management program in primary care on hospital readmissions.

Poorly executed transitions in care from hospital to home are associated with increased vulnerability to adverse medication events and hospital readmissions, and also excess healthcare costs. Efforts to improve care coordination on hospital discharge have been shown to reduce hospital readmission rates but often rely on interventions that are not fully integrated within the primary care setting. The Patient Centered Medical Home (PCMH) model, whose core principles include care coordination in the posthospital setting, is an approach that addresses transitions in care in a more integrated fashion. We examined the impact of multicomponent transition management (TM) services on hospital readmission rates and time to hospital readmission among 118 patients enrolled in a TM program that is part of Care By Design, the University of Utah Community Clinics' version of the PCMH. We conducted a retrospective analysis comparing outcomes for patients before receiving TM services with outcomes for the same patients after receiving TM services. The all-cause 30-day hospital readmission rate decreased from 17.9% to 8.0%, and the mean time to hospital readmission within 180 days was delayed from 95 to 115 days. These findings support the effectiveness of TM activities integrated within the primary care setting.

Organizational culture associated with provider satisfaction.

BACKGROUND: Organizational culture is key to the successful implementation of major improvement strategies. Transformation to a patient-centered medical home (PCHM) is such an improvement strategy, requiring a shift from provider-centric care to team-based care. Because this shift may impact provider satisfaction, it is important to understand the relationship between provider satisfaction and organizational culture, specifically in the context of practices that have transformed to a PCMH model. METHODS: This was a cross-sectional study of surveys conducted in 2011 among providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design. Measures included the Organizational Culture Assessment Instrument and the American Medical Group Association provider satisfaction survey. RESULTS: Providers were most satisfied with quality of care (mean, 4.14; scale of 1-5) and interactions with patients (mean, 4.12) and were least satisfied with time spent working (mean, 3.47), paperwork (mean, 3.45), and compensation (mean, 3.35). Culture profiles differed across clinics, with family/clan and hierarchical cultures the most common. Significant correlations (P ≤ .05) between provider satisfaction and clinic culture archetypes included family/clan culture negatively correlated with administrative work; entrepreneurial culture positively correlated with the Time Spent Working dimension; market/rational culture positively correlated with how practices were facing economic and strategic challenges; and hierarchical culture negatively correlated with the Relationships with Staff and Resource dimensions. CONCLUSIONS: Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.

Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation.

OBJECTIVE: To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. DATA SOURCE/STUDY SETTING: An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. STUDY DESIGN: Convergent case study mixed methods design. DATA COLLECTION/EXTRACTION METHODS: Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. PRINCIPAL FINDINGS: Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. CONCLUSIONS: Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.

Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings.

PURPOSE: We examined quality, satisfaction, financial, and productivity outcomes associated with implementation of Care by Design (CBD), the University of Utah's version of the patient-centered medical home. METHODS: We measured the implementation of individual elements of CBD using a combination of observation, chart audit, and collection of data from operational reports. We assessed correlations between level of implementation of each element and measures of quality, patient and clinician satisfaction, financial performance, and efficiency. RESULTS: Team function elements had positive correlations (P ≤.05) with 6 quality measures, 4 patient satisfaction measure, and 3 clinician satisfaction measures. Continuity elements had positive correlations with 2 satisfaction measures and 1 quality measure. Clinician continuity was the key driver in the composite element of appropriate access. Unexpected findings included the negative correlation of use of templated questionnaires with 3 patient satisfaction measures. Trade-offs were observed for performance of blood draws in the examination room and the efficiency of visits, with some positive and some negative correlations depending on the outcome. CONCLUSIONS: Elements related to care teams and continuity appear to be key elements of CBD as they influence all 3 CBD organizing principles: appropriate access, care teams, and planned care. These relationships, as well as unexpected, unfavorable ones, require further study and refined analyses to identify causal associations.

Virtuous cycles: patient care, education, and scholarship in the patient-centered medical home.

BACKGROUND: Family medicine needs to enhance its scholarly contributions. The discipline is beginning to do so by developing virtuous cycles in which scholarship, education, and clinical care in the patient centered medical home are mutually reinforcing.

Correlation of the Care by Design primary care practice redesign model and the principles of the patient-centered medical home.

BACKGROUND: Health care reform requires major changes in the organization and delivery of primary care. In 2003, the University of Utah Community Clinics began developing Care by Design (CBD), a primary care model emphasizing access, care teams, and planned care. In 2007, leading primary care organizations published joint principles of the patient-centered medical home (PCMH), the basis for recognition of practices as PCMHs by the National Committee for Quality Assurance (NCQA). The objective of this study was to compare CBD and PCMH metrics conceptually and statistically. METHODS: This was an observational study in 10 urban and rural primary care clinics including 56 providers. A self-evaluation included the CBD Extent of Use survey and self-estimated PCMH values. The main and secondary outcome measures were CBD scores and PCMH values, respectively. RESULTS: CBD and PCMH principles share common themes such as appropriate access, team-based care, the use of an augmented electronic medical record, planned care, and self-management support. CBD focuses more on the process of practice transformation. The NCQA PCMH standards focus more on structure, including policy, capacity, and populated electronic medical record fields. The Community Clinics' clinic-level PCMH/CBD correlations were low (P > .05.) CONCLUSIONS: Practice redesign requires an ability to assess uptake of the redesign as a transformation progresses. The correlation of CBD and PCMH is substantial conceptually but low statistically. PCMH and CBD focus on complementary aspects of redesign: PCMH on structure and CBD on process. Both domains should be addressed in practice reform. Both metrics are works in progress.

Improving colonoscopy referral rates through computer-supported, primary care practice redesign.

This quality improvement project was designed to improve rates of referral for colonoscopy screening in the Utah Health Research Network, University of Utah Community Clinics. This study was conducted between October 2004 and June 2007 with the main intervention being a clinic workflow modification using computerized screening reminders embedded in the electronic medical record (EMR). The intervention led to sustained improvement, largely driven by the performance of two network clinics. This study demonstrates that a robust EMR, with decision prompts, accompanied by clinic workflow changes and feedback to providers, can lead to sustained change in the rates of colonoscopy referral.

Evaluating the accuracy of existing EMR data as predictors of follow-up providers.

In order to evaluate the accuracy of existing EMR data in predicting follow-up providers, a retrospective analysis was performed on six months of data for inpatient and ED encounters occurring at two hospitals, and on related outpatient data. Sensitivity and Positive Predictive Value (PPV) were calculated for each of eight predictors, to determine their effectiveness in predicting follow-up providers. Our findings indicate that access to longitudinal patient care records can improve prediction of which providers a patient is likely to see post-discharge compared to simply using Primary Care Provider data from admissions records. Of the predictors evaluated, a patient's past appointment history was the best predictor of which providers they would see in the future (PPV = 48% following inpatient visits, 35% following emergency department visits). However, even the best performing predictors failed to predict more than half of the follow-up providers and might generate many "false" alerts.