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Learn how Crozer-Keystone Family Medicine Residency's Center for Family Health (CFH) restructured their teams and clinic space to elevate their team-based care model.
During Patient-Centered Medical Home (PCMH) recognition, Centers for Family Health (CFH) at Crozer-Keystone Health System purposefully changed from a physician-centered team to a patient-centered team with a medical assistant (MA) director. While focusing on the patient, CFH realized that it takes an inter-professional team to care for all the bio-psychosocial needs of their patients in addition to addressing social determinants of health. The holistic needs of CFH's patients are best addressed in a team-based office that improves quality of care and overall health.
The goals of CFH's care model redesign were to promote and expand the role of the MA to:
Enhance clinical care
Meet preventive care needs
The intent is not to offload work onto MAs, but rather to educate and empower them to share responsibility for patient care and free physicians to focus on clinical decision-making. Residents and MAs were heavily involved in the redesign of the new workstations, office flow, and team roles.
CFH created 3 color teams, each with 3 to 4 faculty attendings, 2 MAs, and 9 to 10 residents caring for about2 000 patients. An RN care manager, pharmacist, social worker, and psychology students work across all 3 of the color teams.
The teams were then divided into 6 teamlets to further improve continuity and population management during each clinic session. Each teamlet consists of 1 provider and 1 MA. Several medical students work with teamlets of R2s or R3s. Faculty members usually work with the same MA on their color team. Residents work with any of the 6 MAs, preferentially with the 2 MAs from their color team. By breaking 3 larger teams into 6 teamlets, CFH is able to better manage the 1 000-patient panel for each teamlet than the larger patient panel when CFH had 3 teams. Figure 1 illustrates the traditional model that the CFH was using and compares it to this new teamlet model.
This theoretical diagram depicts the differences between a traditional model and a teamlet model with 3 teamlets. In the traditional team model each resident worked with various MAs and vice versa (left) whereas in the teamlet model each MA is in a stable pair with a provider (right). The teamlet structure shown is an example of 1 clinic session. In both models the arrows represent lines of communication. Although not depicted here, multiple residents could be assigned to work with 1 MA during a clinic session.
MAs are trained in a standardized manner to work similarly with different providers. MAs review patient charts and do pre-visit planning using health care maintenance checklists called Huddle Sheets (see example at the end of this case report).
Use a huddle sheet like this one to prepare for patient visits and to help schedule follow-up appointments and labs at check-out.
Before each clinic session, MAs prepare a Huddle Sheet on each patient by filling in the status (due or up to date) for each relevant item and when the patient would need appointments for colonoscopies, mammograms, and/or pap smears. Upon patient checkout, the front desk uses the Huddle Sheet to make appropriate appointments. The Huddle Sheet serves as a tool to close the preventive and quality gaps, but also as a communication tool from the clinical area to the front desk.
For the first 15-30 minutes of each clinic session, the physician–MA–medical student teamlet huddles to discuss their patient list. Using the prepared Huddle Sheet, teamlets review each patient on the schedule and discuss the issues to address during the visit and what preventive health tasks are due. Roles are assigned to each team member for each encounter, including the embedded interprofessional team. The behavioral health director or RN care manager approaches teamlets to discuss relevant patients on the schedule during huddles.
An intake form in the electronic health record (EHR) enables MAs to accomplish more during the visit. During patient intake, MAs are able to:
Complete a brief history of present illness
Ask if refills are needed
Screen for depression
Ask whether the patient has a durable power of attorney
Ask if the patient smokes or is open to quitting
Ask if the patient has religious beliefs affecting their health care
Ask whether the patient has been to other health care facilities since their last visit
MAs also order labs, referrals, mammograms, and colonoscopies for providers to review and sign. Based on the patient's complaints, MAs might also check visual acuity, orthostatics for dizziness, pulse oximetry for respiratory issues, or urinalysis for urinary complaints before handoff to the clinician. For patients with diabetes, MAs make sure A1c, urine albumin-to-creatinine ratio (ACR), lipids, eye exams, and foot exams are completed.
In the new model, each teamlet sits side-by-side at 1 of 6 workstations in a co-located workroom, which is attached to a space for precepting. Figure 2 compares the old traditional workroom layout to the new co-located teamlet model. Checklists and other clinic workflow documents are kept in binders at every co-located teamlet station. Between patients, MAs check their inboxes, help providers with forms, and update the patients' proactive care flowsheets. MAs also attend Lunch and Learn sessions to deepen their education. The clinic continues to work on promoting MAs as the team member running the teamlet and teaching residents to work with MAs in their expanded roles.
In the traditional care model, MAs and health care providers work in their respective areas and have to find one another to communicate (left). In a team room where workspaces are consistently in the same physical space, team members work side-by-side and are able to communicate more easily (right). Co-location enhances a collaborative and cohesive team culture and facilitates minute-to-minute communication among team members.
“It's hard to find a place to work like this clinic…I feel like I've kind of been spoiled.”—Resident
Teamlets have greatly improved CFH's team-based care model. Patient continuity increased as the teams became smaller teamlets. Physician and team member satisfaction grew as physicians felt that the team could handle the multitude of issues for patients and the team members felt empowered to make changes in CFH's care. CFH measures improvement on overall quality of care and on satisfaction surveys conducted for team members, residents, and faculty Overall, CFH has seen quality of care measures improve at the same time as physician, staff, and patient satisfaction.
Crozer-Keystone Health System, headquartered in Springfield, Pennsylvania, is the leading health care provider and largest employer in Delaware County. The system supports a robust primary care network with more than 30 outpatient offices and 4 hospitals.
Family medicine residents train at the CFH in both Springfield and Upper Darby. The patient populations served include a variety of cultures, ethnicities, and socioeconomic backgrounds, giving residents an opportunity to practice culturally sensitive, patient-oriented medicine. Crozer-Keystone accepts up to 9 residents per training year. The 16 family medicine faculty members and 27 family medicine residents care for more than 25 000 patients every year in a National Committee for Quality Assurance (NCQA) Level 3 PCMH setting.
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