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Team-Based Care Case Report: North Ohio Heart

North Ohio Heart has followed an efficient, team-based care approach for more than 20 years. With an established staff the clinic's team functions like a well-oiled machine with the more than 20 cardiologists often seeing upwards of 55 patients a day each. As more quality improvement (QI) efforts came into play and with the recent merger between the cardiology clinic and a primary care group, North Ohio Heart found they needed to adapt their team-based care approach across multiple sites. In the cardiology setting, there are two LPNs and one MA assigned to each physician. In primary care there is one LPN and one MA per physician.

Quality improvement (QI) placed more pressure on the clinic to address every measure, which increased rooming time. For example, additional time was required to perform hypertensive measures and have conversations about Pneumovax with anyone over age 65. These tasks could be shifted from the physician to the nurse, but as the nurse's plate became fuller they realized that the staffing model needed to change.

Medical assistants began to take on some of the rooming duties that nurses usually performed, such as gathering information on immunizations and labs, updating the patient record and reconciling medications to capture QI and Meaningful Use measures. This shifted the workflow so that nurses now entered the room with the physician and took over the computer to prompt the doctor with pertinent patient information. Nurses still handled after-visit responsibilities, including instructions, education and the clinical summary. Team meetings were critical for determining who on the team would take on a new task.

To accommodate the new workflow, North Ohio Heart has had to hire additional MAs. These MAs receive ongoing training so that they could be flexible and take on new responsibilities as the practice required. Training is implemented as soon as the MA is hired and covers topics that directly relate to the practice's quality measures. Every office has a clinical trainer who meets with the team on a monthly basis to assess performance and discuss training needs, as well as performs competency checks. The trainers share ideas across sites for consistency. The practice manager held regular meetings to get input on how to improve the approach and then huddled with the doctors and staff to implement changes. These conversations are key to the success of team-based care.

One challenge with the new workflow was keeping the registration team updated on new or different steps. As a result, they initially did not always ask patients the right questions or enter information in the correct places in the EHR. This has since been fixed, but it took some time for the team to become comfortable with the new approach. Metrics are now tracked using reports from the EHR.

The practice manager at North Ohio Heart is always thinking about ways to increase employee and patient satisfaction. Communication has helped the team stay positive and also is also helping make the expansion of team-based care into the primary care setting successful. The practice's patients are now more involved in their healthcare, asking questions about the clinical summary and overall feel more empowered. Charts are more accurate with a team approach, which patients also appreciate. North Ohio Heart wouldn't be able to provide excellent care with the volume of patients they see without using team-based care.

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