Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

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Synopsis

A study of medical practices recognized as patient-centered medical homes found that a team approach to primary care was fostered by: delegating more of physicians’ nonclinical tasks to other staff; soliciting staff input on workflow modifications and feeding back data to the team; expanding the roles of medical assistants and nurses; and holding regular team “huddles.”


The Issue

“Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity.”

A team approach to primary care—typically involving a lead clinician, nurses, medical assistants, care managers, and clerical staff—can help practices deliver services more efficiently, improve patients’ access to care, and reduce physician burnout. However, providers lack practical guidance on how to function as a team. Commonwealth Fund–supported researchers interviewed 63 clinicians and other staff from 27 primary care practices to find out how they sought to overcome challenges to providing team-based care.


Key Findings

  • Although delivering care as a team requires that physicians delegate tasks to other staff members, physicians often are hesitant to do so. Interviews revealed that this resistance can be overcome by introducing task delegation slowly and incrementally, starting with standing orders for tasks that physicians felt were safest to hand off—for example, having medical assistants perform a urinalysis for patients with urinary tract infection symptoms.
  • Assigning routine tasks to medical assistants and licensed practical nurses can increase job satisfaction for physicians, who feel they now have more time to focus on patients’ complex needs. Interviews also revealed that job satisfaction improves for medical assistants, who feel more involved in patient care.
  • Twenty-three of the 27 practices in the study mentioned staff “huddles” as central to maintaining communication. Huddles are generally used to clarify the day’s “game plan,” often beginning with a review of key issues for those patients scheduled for visits.
  • Other strategies to improve communication include colocating the physician, nurse, and medical assistant; promoting a culture in which staff could feel comfortable providing feedback; and taking advantage of certain electronic health record functions, like instant messaging and task lists.
  • Nurse care managers were found to be important team members, in particular because of their work with patients between visits in helping them manage chronic conditions and because of the managers’ role in developing care plans in partnership with patient and physician.
  • Nearly all respondents described patients as a member of the team, citing their involvement in identifying health goals, carrying out care plans, self-managing chronic conditions, and making decisions about their care.
  • To maximize patients’ familiarity with team members, most practices limit the core clinical team to two or three staff members who have ongoing interaction with the patients. Some practices gave patients a card with names, titles, roles, and contact information of team members.
  • Most practices had not participated in any formal teamwork training, but interviewees reported interest in training, particularly if it were conducted on-site.

The Big Picture

Most problematic for the primary care practices in the study were broader health system challenges beyond their control—among them the inadequacy of the fee-for-service payment system for reimbursing practices for certain medical home services. In these instances, practices try to turn to effective clinical leaders who have training in changing care processes.


About the Study

The researchers selected a random sample of patient-centered medical homes in different geographic regions from a National Committee for Quality Assurance (NCQA) database. Most of the 27 practices interviewed received a high score on NCQA’s “practice team element,” but the sample also included one low-scoring practice per region for comparison. Practice team members, ranging from physicians to front-desk staff, were interviewed between May and December 2013.


The Bottom Line

Enhanced teamwork can increase provider satisfaction and productivity within primary care practices, but more staff training—preferably on-site—is necessary.

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Publication Details

Publication Date:
November 18, 2014
Authors:
Ann S. O’Malley, Rebecca Gourevitch, Kevin Draper, Amelia Bond, and Manasi A. Tirodkar
Summary Writer:
Deborah Lorber
Citation:
A. S. O’Malley, R. Gourevitch, K. Draper et al., “Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study,” Journal of General Internal Medicine, published online Nov. 11, 2014.
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