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Team-Based Care Case Report: Forest View Pediatrics

Forest View Pediatrics in New Berlin, WI, has helped their community raise and nurture kids for three generations. In 2013, several changes contributed to dissatisfaction among the practice's providers, patients and their families. First, going live on EPIC introduced major confusion and inefficiency. This was compounded when the group simultaneously began a 20-month process of becoming recognized as a patient-centered medical home. These changes, along with greater emphasis on meeting quality metrics, resulted in providers becoming increasingly frustrated with the growing demands of their work.

Dr. David Lautz, one of eight pediatricians in the practice, found that the introduction of the computer screen in the exam room was the biggest problem. It was a distraction and detrimental to communication with patients. He felt he was missing important cues from patients and parents because he was no longer able to make eye contact. In addition, he often found himself working late into the night to complete his charting. Initially, he requested a scribe to support him. Then in 2015, in an attempt to support providers in meeting similar challenges across Children's Hospital of Wisconsin's primary care clinics, the concept of team-based care was introduced. Dr. Lautz immediately saw the potential and agreed to pilot the new model at Forest View Pediatrics.

He piloted the team-based care model with two full-time nurses for one year. At the beginning of the day, the team huddles to discuss their schedule. This is essential to prepare for patients who have behavioral issues and may require a longer visit time. In addition, it helps the nurse identify which templates need to be opened at the outset of the exam. The nurse is present for the entire visit. After she completes the history and Dr. Lautz enters the room, she stays in the room as the scribe during the physical. This ensures that the physical is completely documented. At the conclusion of the visit, the nurse remains in the exam room to reinforce Dr. Lautz's recommendations and offer training for the parents. The content of the patient's after-visit summary is now less generic and more useful.

The team-based care model also allows flexibility in the nurses' schedule, in that they can be reassigned first thing in the morning to meet the needs of the clinic for that day. For example, if Dr. Lautz's first appointment of the day is with two siblings, it is most efficient to have a computer-savvy nurse in the room. This capacity for “flexing” also better accommodates staff vacations, sick time, and nurse preferences. Some nurses are more skilled and enjoy team care whereas others find it stressful because it means more patients must be seen during the day. In addition, some nurses are less comfortable than others with using the EHR system to document visits. In these rare situations, the nurse acts as a scribe-runner, meaning that they are not the primary scribe accompanying Dr. Lautz in the exam room but instead spend the majority of their day rooming patients or administering vaccines.

With one year of the team-based approach under their belts, nurses at Forest View Pediatrics are now able to pick up on Dr. Lautz's signals to adapt the physical as needed. They feel comfortable interjecting and asking for clarification on terminology or the patient's follow-up care. The team works more efficiently, which has translated to improvements in scheduling. Wait times have decreased and more patients can be scheduled during the day.

This model has also greatly improved care delivery at Forest View Pediatrics. For Dr. Lautz, making eye contact with the patient and being able to pick up on nonverbal cues has reduced the possibility of overlooking potentially important problems. “I was having a busy day and had just come from a visit with a child who had behavioral issues. My next exam was with a teenage patient. We recently introduced adolescent depression screening and she scored high on the screen. I didn't know her score when I entered the room but I could see that she was visibly upset about something. If we weren't using team-based care, I probably would have gone straight to the computer and not noticed her distress. Instead, I was able to take the time to talk to her, comfort her, and figure out how to take care of her.”

Overall, team-based care has created a collegial atmosphere in the practice. Patients and staff alike feel the change and appreciate it. Patients and their families can depend on experiencing consistency and continuity during and across visits for years to come. Dr. Lautz now describes himself as happier than he has ever been in pediatric practice.

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