Leaders in health care and practicing physicians recognize the need for changes in how health care is delivered.1-3 Despite this awareness, though, barriers to meaningful change persist and the current practice environment wherein physicians must routinely spend 2 hours on electronic health records (EHRs) and desk work for every hour of direct face time with patients4 is driving trainees away from ambulatory specialties and is contributing to physicians’ decisions to reduce their practices to part-time, retire early, or leave medicine altogether.5,6 Those who persevere in this environment with heavy administrative burdens run the increasing risk of burnout.7
Some physicians and practices are responding by taking creative measures to reform the way patient care is delivered. Bellin Health—a 160-provider, multispecialty health system in northeast Wisconsin where one of the authors (JJ) works—introduced an advanced team-based care (aTBC) model between November 2014 and November 2018, starting with our primary care providers. The development and introduction of this new model arose from an iterative, multidisciplinary process driven by the desire to transform the Triple Aim—enhancing patient experience, improving population health, and reducing costs—into a Quadruple Aim8 by additionally focusing on improving the work life of health care providers, which, in turn, will help achieve the first 3 goals. In introducing an aTBC model, Bellin Health focused on 3 elements: office visit redesign, in-basket management redesign, and the use of extended care team members and system and community resources to assist in the care of complex and high-risk patients.
Herein we describe the 3 components of our aTBC model,1,9 identify the barriers that existed in the minds of multiple stakeholders (from patients to clinicians and Bellin executives), and describe the strategies that enabled us to overcome these barriers.
The impetus behind our move to aTBC
Bellin Health considered a move to an aTBC model to be critical in light of factors in the health care environment, in general, and at Bellin, in particular. The factors included
- an industry-wide shift to value-based payments, which requires new models for long-term financial viability.
- recognition that physician and medical staff burnout leads to lower productivity and, in some cases, workforce losses.5,6 Replacing a physician in a practice can be difficult and expensive, with cost estimates of $500,000 to more than $1 million per physician.10,11
- a belief that aTBC could help the Bellin Health leadership team meet its organizational goals of improved patient satisfaction, achieve gains in quality measures, enhance engagement and loyalty among patients and employees, and lower recruitment costs.
A 3-part aTBC initiative
■ Part 1: Redesign the office visit
We redesigned staffing and workflow for office visits to maximize the core skills of physicians, which required distributing ancillary tasks among support staff. We up-trained certified medical assistants (CMAs) and licensed practical nurses (LPNs) to take on the new role of care team coordinator (CTC) and optimized the direct clinical support ratio for busier physicians. For physicians who were seeing 15 to 19 patients a day, a ratio of 3 CTCs to 2 physicians was implemented; for those seeing 20 or more patients a day, we used a support ratio of 2:1.
The role of CTC was designed so that he or she would accompany a patient throughout the entire appointment. Responsibilities were broken out as follows:
Pre-visit. Before the physician enters the room, the CTC would now perform expanded rooming functions including pending orders, refill management, care gap closure using standing orders, agenda setting, and preliminary documentation.12
Visit. The CTC would now hand off the patient to the physician and stay in the room to document details of the visit and record new orders for consults, x-ray films, referrals, or prescriptions.13 This intensive EHR support was established to ensure that the physician could focus directly on the patient without the distraction of the computer.
Continue to: Post-visit