RE: Team Care for 21st Century Family Medicine

[Guest guest]

So, each person bills for what they do?

>

>

> I know a Family Doc in Colorado who sort of does this.

> Has 3 nurses -- they do the majority of the history taking -- he comes in

> and does the exam and makes recommendations on Dx and Tx.

> The the nurses do the discharge counseling, coordination of care, etc.

> He can easily see 30+ patients per day with this model and most of the

> documentation is done by the nurses.

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

[Guest guest]

RE Is team care the best care?

Question is if this is worse?

I doubt it -- if the volume is high, then this could be done.

I personally think it would be better for this style of practice to use the nurses rather than a PA/NP as long as the doc works with the pt on decision making.

Matt in Western PA

Team Care for 21st Century Family Medicine

Interesting angle about Team Care.

Can't quite decide if this goes against the IMP model or could be incorporated into the IMP model (if one wasn't solo-solo).

No connections to the Trade Marked concept -- it was mentioned on another list and I thought it was interesting.

I know a Family Doc in Colorado who sort of does this.

Has 3 nurses -- they do the majority of the history taking -- he comes in and does the exam and makes recommendations on Dx and Tx.

The the nurses do the discharge counseling, coordination of care, etc.

He can easily see 30+ patients per day with this model and most of the documentation is done by the nurses.

Not saying it's for everyone, just an interesting way.

Locke, MD

http://www.familyteamcare.org/what_is_team_care.html

Liberating the Family PhysicianTMThe Handbook of Team Care for 21st Century Family Medicine.

The definition of team care is a physician using 1-2 well-trained assistants to help him/her execute a patient visit. This is in contrast to traditional care in which the physician does 95% of the patient visit. Under team care the physician does 20-50% of the patient visit. The heart of this innovation of team care is the developing of an assistant who is capable of taking and documenting a complete patient history for the visit. To be comprehensive, a complete history can be very time consuming—usually the longest part of the visit. However, it is extremely important to understand that even though this part is often lengthy, this step involves no decisions. This is a crucial point. Since this step consists of only the collection of data, it is not essential that a physician participate. Standard protocols, experience, and good patient care indicate that most patient visits can be broken down into four discrete components:Part l: Data gathering and communication of the data. Part 2: Analysis of data and pertinent physical exam. Part 3: Decision making and development of a plan. Part 4: Implementation of the plan and patient education. Although some of these components do not necessarily require a physician, tradition has generally placed all four of them within the purview of the physician. The basis for the team care is that a well-trained assistant can readily perform the information gathering and communication function (part 1) and implement a plan and provide effective patient education (part 4). In this model, the physician would then be able to focus on analysis of the data and the physical exam (part 2) as well as carry out the required decision making and development of a treatment plan (part 3). In terms of time, parts 1 and 4 are often the longest in duration, whereas, parts 2 and 3 can be generally accomplished more quickly. With a well-trained RN or LPN now doing part 1 and part 4, data can be collected and recorded with less pressure and time restrictions. By removing the physician from the parts of the visit not requiring his/her expertise, the physician has more time to do what only the physician can do. This allows the physician to see more patients without sacrificing quality of care or patient satisfaction. These are the foundation principles of team care. Its efficacy lies not in a complex approach, but in a disciplined, clearly outlined process wherein well-trained assistants take on a more active role in the patent visit. The result is a change in the patient/caregiver dynamic that enables the physician to see more patients with a higher level of attention.

[Guest guest]

Pays to think I would enjoy this sort of clinic model.

That was until I found that in order to get sort of talent would take from a

nurse, it had to pay something like $50 to $70 per hour. Sure, cheaper

nurses can be had, but ones that you would actually trust?...Very

expensive. If I could see 30 patients per day, but the collections from the

first three every hour went to pay the nurses, then the next one to general

overhead, there’s none left for me.

I didn’t read about Team Care yet…. Will it bowl me

over?

Annie

From:

[mailto: ] On Behalf Of Locke's in

Colorado

Sent: Sunday, January 13, 2008 9:59 PM

To:

Subject: Team Care for 21st Century Family

Medicine

Interesting angle about Team

Care.

Can't quite decide if this

goes against the IMP model or could be incorporated into the IMP model (if one

wasn't solo-solo).

No connections to the Trade

Marked concept -- it was mentioned on another list and I thought it was

interesting.

I know a Family Doc in

Colorado who sort of does this.

Has 3 nurses -- they do the

majority of the history taking -- he comes in and does the exam and makes

recommendations on Dx and Tx.

The the nurses do the

discharge counseling, coordination of care, etc.

He can easily see 30+

patients per day with this model and most of the documentation is done by the

nurses.

Not saying it's for everyone,

just an interesting way.

Locke, MD

http://www.familyteamcare.org/what_is_team_care.html

Liberating the Family

PhysicianTM

The Handbook of

Team Care for 21st Century Family Medicine.

The

definition of team care is a physician using 1-2 well-trained assistants

to help him/her execute a patient visit. This is in contrast to

traditional care in which the physician does 95% of the patient visit.

Under team care the physician does 20-50% of the patient visit.

The heart of this innovation of team care is the

developing of an assistant who is capable of taking and documenting a

complete patient history for the visit. To be comprehensive, a complete

history can be very time consuming—usually the longest part of the

visit. However, it is extremely important to understand that even though

this part is often lengthy, this step involves no decisions. This is a

crucial point. Since this step consists of only the collection of data,

it is not essential that a physician participate.

Standard protocols, experience, and good patient

care indicate that most patient visits can be broken down into four

discrete components:

Part l: Data gathering and communication of the data.

Part 2: Analysis of data and

pertinent physical exam.

Part 3: Decision making and development of a plan.

Part 4: Implementation of the plan and patient

education.

Although some of these components do not

necessarily require a physician, tradition has generally placed all four

of them within the purview of the physician. The basis for the team care

is that a well-trained assistant can readily perform the information

gathering and communication function (part 1) and implement a plan and

provide effective patient education (part 4). In this model, the

physician would then be able to focus on analysis of the data and the

physical exam (part 2) as well as carry out the required decision making

and development of a treatment plan (part 3). In terms of time, parts 1

and 4 are often the longest in duration, whereas, parts 2 and 3 can be

generally accomplished more quickly.

With a well-trained RN or LPN now doing part 1

and part 4, data can be collected and recorded with less pressure and

time restrictions. By removing the physician from the parts of the visit

not requiring his/her expertise, the physician has more time to do what

only the physician can do. This allows the physician to see more patients

without sacrificing quality of care or patient satisfaction.

These are the foundation principles of team

care. Its efficacy lies not in a complex approach, but in a disciplined,

clearly outlined process wherein well-trained assistants take on a more

active role in the patent visit. The result is a change in the

patient/caregiver dynamic that enables the physician to see more patients

with a higher level of attention.

[Guest guest]

Interesting idea. As I contemplated this (trying to be open minded), one thing struck me.

The article mentions:

" complete patient history for the visit...Since this step consists of only the collection of data, it is not essential that a physician participate... "

Ahh, but the trick is knowing what data your are trying to collect...

I was taught in medical school by a wise old country doc, that if I just listened well enough, the patients would tell me what is wrong with them. I have found this to be true, and to me has much more to do with the true " art " of healing than either the physical exam or the decision making portion that they describe as worthy of a physician's expertise.

Turning a physician into a healer involves the steps they are trying to cut out of the process.

I truly enjoy the thought-provoking information you bring to the list-serve, . Thanks.

Durango, CO

[Guest guest]

I have experience with something kind of like this. I worked for an

FQHC rural non-profit outfit. They got some money from the

government to bring in a consultant and tried this out. Supposedly,

it has worked in some offices, but didn't work for us.

I actually had three MA's. One handled PA's, referral paperwork and

phone calls, etc. and the other two would room patients, take vitals

and act as my " scribe " . The theory was that I could just go from

room to room and the scribes would just write down the subjective

portion of the note based on what the patient and I were saying, I

would say my exam aloud as I did it. Then I would " announce " my

assessment and plan so it could be written and I would sign the note

and leave the room. After that the MA would stay behind and execute

the plan, eg draw the labs in the exam room, etc. and get it ready

for the next patient.

In theory, kind of interesting. The execution was a problem. The

MA's had trouble sorting out the important from the unimportant info

and tended to get bored and let their minds wander during visits

that were long. Since I was an FP with alot of chronically ill

adults, I had a lot of LONG visits.

In the end, the dysfunction of the office won out and the thing

crashed and burned. My male MA got fired for sexually harassing one

of my female MAs right in front of two witnesses. (The organization's

original solution was to offer to transfer him to another office

to " fix " things. I told them NO WAY.) MA #2 had a bunch of marital

problems and quit. I was left with my original MA and went back to

the old way of doing things. (BTW, I didn't hire these folks and I

left this employer/high school drama club situation within a few

months of this program failing.)

I think the overhead was going to be too high, BTW.

I think your collection of information still involves making

decisions. You need good training and judgement to really know which

questions to ask as the interview progresses. If you are going to get

someone who is properly trained to make these decisions while

gathering info, you might as well get a PA or NP and let them do

their thing and bill for it.

[Guest guest]

What and excellent topic.

This exposes one of the most important issues facing us as we explore the

root causes of failure in the U.S. health care system as well as key

aspects of health care.

Team care is not antithetical to the IMP model. It is the opposite

end of the spectrum of the solo/solo version, but has equal claims as a

hypothesis on how to deliver effective care to achieve excellent

outcomes. In the IMP model we're defining certain behaviors

(putting the patient at the center of care, improving access &

efficiency, etc) that allow us to be patient-centered medical

homes.

The problem I have with the current press and momentum behind pay for

performance and the language and measurement of the current medical home

model is that it is one--big-team-fits-all and implies (and often states

explicitly) that small & solo practices cannot be medical

homes.

They state this for two reasons:

1: Solo/small practices are less likely to measure and report

quality and less likely to engage in quality improvement.

This is true.

This is due to the current misapprehension of how to measure and report

quality, based on the idea that disease and disease management defines

quality and quality improvement.

This is a false assumption.

A: Disease is important, but when we focus on disease and forget

that we treat people we miss important clues to

" non-compliance " and therefore write off significant parts of

the population we serve.

True patient-centered care treats people and in doing so helps them

manage their condition(s), one of the reasons we see improved population

experience of care and clinical outcomes in IMPs.

B: Pursuit of disease management quality reporting requires

significant investment in computer infrastructure and staff time to

populate data fields. Larger organizations absorb this cost (and

suffer from high overhead and then blame the practices and then crack the

productivity whip) and have data and quality improvement staff (that

drive up overhead which they pass on to the practices, thus making the

practices less financially stable, so they crack the productivity whip

again).

IMPs on the other hand use patient reported outcome measures that come at

no cost and reflect the wide base of the population they serve (thus

solving the " quantity insufficient " problem inherent in all

payer/disease specific p4p systems).

In the IMP project we show not only that solo/small practice docs are

willing to engage in quality measurement and improvement - when we have

reasonable and accessible measurement strategies/tools - but that our

results are better than those of large systems often held up as exemplars

of quality measurement & improvement.

2: The big team is the only way to achieve effective care

delivery

False assumption based on the observation (and self report) that docs are

too busy to engage in effective self management support and patient

centered care.

This is false because it merely addresses the symptom of the current

dysfunctional delivery system of health care in the U.S.

" Because docs in typical practices usually have to work at a pace

that cannot support effective self management support and

patient-centered care, they must delegate the work to another. "

Once again we miss the key point: Get off the hamster wheel.

Stop working at a pace that cannot support effective care.

We have data from the IMP project that demonstrates the success of this

approach.

So I seem to trash the idea of team based/delegated care. I want to

make the point again that I see team based care as part of the continuum

of hypotheses likely to be able to achieve the results we all want and

need. I worry that a large team is a difficult thing to

manage. As pointed out in an earlier post (and what we see in

sports every day), excellent teams are rare and take exceptional

individuals working in ways alien to the way we are trained.

Is the big team approach likely to achieve the results? Not until

we solve some fundamental problems:

Increased payment to primary care to support the extra costs inherent

in the big team model

Train physicians on how to be team players (flying in the face of the

selection for an inculcation of individualism and anti-team behavior)

Use measurement strategies that reflect important patient outcomes

and not just disease

Use measurement strategies that are affordable and accurately

represent care delivery Without these fundamental changes the big team model will fail for

the following reasons:

1: It is not truly patient-centered

As noted in the article cited as well as in the measures of success in

the NCQA's evaluation of the PC-MH, the approach is aimed at diagnosis

and treatment of disease. This misses one of the essential points

of primary care. Remember that one of the key principles of primary

care is to treat people and not just disease. The " disease

management " approach has been around for a long time and has failed

to deliver the results we want and need.

Aside from those IMPs in the project, I've yet to see more than posturing

around an empty house.

2: It fails to account for the unsupportable data burden inherent

in the measurement paradigm

3: It fails to account for 50% of the practices that a small or

solo.

4: It fails to account for the vicious cycle of increasing practice

overhead inherent in the current payment and " management "

strategies. (See figure below)

Gordon

At 11:36 PM 1/13/2008, you wrote:

Interesting idea. As I

contemplated this (trying to be open minded), one thing struck me.

The article mentions:

" complete patient history for the visit...Since this

step consists of only the collection of data, it is not

essential that a physician participate... "

Ahh, but the trick is knowing what data your are trying to

collect...

I was taught in medical school by a wise old country doc,

that if I just listened well enough, the patients would tell me what is

wrong with them. I have found this to be true, and to me has much

more to do with the true " art " of healing than either the

physical exam or the decision making portion that they describe as worthy

of a physician's expertise.

Turning a physician into a healer involves the steps they

are trying to cut out of the process.

I truly enjoy the thought-provoking information you bring to

the list-serve, . Thanks.

Durango, CO

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[Guest guest]

, I tried responding

a couple of times, but it appears I am too long winded. Here is my response in

a word document.

[Guest guest]

some may prefer a synthetist (read IMP cottage industry) manner, others may prefer a reductionist (read factory division of labor) manner. some may define this on the basis of being a "team player", and whether there are and what are the practice measurements. unfortunately, what i see is more the process of medicine enslaved to the production of money, rather than a harnessing of efficiency to the process of medicine. i believe that is the heart of the matter-- there's big money to be made, and you just can't make the kind of money in a cottage industry that you can in a factory. LL "L. Gordon " wrote: What and excellent topic.This exposes one of the most important issues facing us as we explore the root causes of failure in the U.S. health care system as well as key aspects of health care.Team care is not antithetical to the IMP model. It is the opposite end of the spectrum of the solo/solo version, but has equal claims as a hypothesis on how to deliver effective care to achieve excellent outcomes. In the IMP model we're defining certain behaviors (putting the patient at the center of care, improving access & efficiency, etc) that allow us to be patient-centered medical homes.The problem I have with the current press and momentum behind pay for performance and the language and measurement of the current medical home model is that it is

one--big-team-fits-all and implies (and often states explicitly) that small & solo practices cannot be medical homes. They state this for two reasons:1: Solo/small practices are less likely to measure and report quality and less likely to engage in quality improvement. This is true. This is due to the current misapprehension of how to measure and report quality, based on the idea that disease and disease management defines quality and quality improvement.This is a false assumption. A: Disease is important, but when we focus on disease and forget that we treat people we miss important clues to "non-compliance" and therefore write off significant parts of the population we serve.True patient-centered care treats people and in doing so helps them manage their condition(s), one of the reasons we see improved population experience of care and clinical outcomes in IMPs.B: Pursuit of disease

management quality reporting requires significant investment in computer infrastructure and staff time to populate data fields. Larger organizations absorb this cost (and suffer from high overhead and then blame the practices and then crack the productivity whip) and have data and quality improvement staff (that drive up overhead which they pass on to the practices, thus making the practices less financially stable, so they crack the productivity whip again). IMPs on the other hand use patient reported outcome measures that come at no cost and reflect the wide base of the population they serve (thus solving the "quantity insufficient" problem inherent in all payer/disease specific p4p systems).In the IMP project we show not only that solo/small practice docs are willing to engage in quality measurement and improvement - when we have reasonable and accessible measurement strategies/tools - but that our results are better than those of large systems often

held up as exemplars of quality measurement & improvement.2: The big team is the only way to achieve effective care deliveryFalse assumption based on the observation (and self report) that docs are too busy to engage in effective self management support and patient centered care.This is false because it merely addresses the symptom of the current dysfunctional delivery system of health care in the U.S. "Because docs in typical practices usually have to work at a pace that cannot support effective self management support and patient-centered care, they must delegate the work to another." Once again we miss the key point: Get off the hamster wheel. Stop working at a pace that cannot support effective care.We have data from the IMP project that demonstrates the success of this approach.So I seem to trash the idea of team based/delegated care. I want to make the point again that I see team based care as part

of the continuum of hypotheses likely to be able to achieve the results we all want and need. I worry that a large team is a difficult thing to manage. As pointed out in an earlier post (and what we see in sports every day), excellent teams are rare and take exceptional individuals working in ways alien to the way we are trained.Is the big team approach likely to achieve the results? Not until we solve some fundamental problems: Increased payment to primary care to support the extra costs inherent in the big team model Train physicians on how to be team players (flying in the face of the selection for an inculcation of individualism and anti-team behavior) Use measurement strategies that reflect important patient outcomes and not just disease Use measurement strategies that are affordable and accurately represent care delivery Without these fundamental changes the big team model will fail for the following

reasons:1: It is not truly patient-centeredAs noted in the article cited as well as in the measures of success in the NCQA's evaluation of the PC-MH, the approach is aimed at diagnosis and treatment of disease. This misses one of the essential points of primary care. Remember that one of the key principles of primary care is to treat people and not just disease. The "disease management" approach has been around for a long time and has failed to deliver the results we want and need. Aside from those IMPs in the project, I've yet to see more than posturing around an empty house.2: It fails to account for the unsupportable data burden inherent in the measurement paradigm3: It fails to account for 50% of the practices that a small or solo.4: It fails to account for the vicious cycle of increasing practice overhead inherent in the current payment and "management" strategies. (See figure

below)GordonAt 11:36 PM 1/13/2008, you wrote: Interesting idea. As I contemplated this (trying to be open minded), one thing struck me.The article mentions: "complete patient history for the visit...Since this step consists of only the collection of data, it is not essential that a physician participate..." Ahh, but the trick is knowing what data your are trying to collect... I was taught in medical school by a wise old country doc, that if I just listened well enough, the patients would tell me what is wrong with them. I have found this to be true, and to me has much more to do with the true "art" of healing than either the physical exam or the decision making portion that

they describe as worthy of a physician's expertise. Turning a physician into a healer involves the steps they are trying to cut out of the process. I truly enjoy the thought-provoking information you bring to the list-serve, . Thanks. Durango, CO Content-Type: image/png; name=7465616d2063617265206f7574636f6d6573.pngX-Attachment-Id: 0.5Content-Disposition: attachment; filename=7465616d2063617265206f7574636f6d6573.pngContent-Type: image/png; name=776879207465616d2063617265.pngX-Attachment-Id: 0.2Content-Disposition: attachment; filename=776879207465616d2063617265.pngContent-Type: image/jpeg; name=catherine___patient03_wyh3.jpgX-Attachment-Id: 0.7Content-Disposition:

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Never miss a thing. Make Yahoo your homepage.

[Guest guest]

RE role of email in pt care.

Email also leverages time for pt care to answer questions before and after visits.

I've found not all will use it (RelayHealth is a flat rate portal you can subscribe to), but for those that will, I've been successful in keeping in touch with several groups of pts--

1) I try to offer results on all tests within 1 week, but for those that email me that they had a test (those done at the hospital I can usually get that evening), I'll review and give them results and copies same day. And staff don't need to get it for me, I print the report into a pdf writer and forward a copy behind the firewall.

2) Pts are asked to email me with nonurgent requests. They know I'll review that night.

3) I find not all pts are comfortable with the platform, so offer it more for those who use email all the time.

Matt in Western PA.

PS -- portal method, so no encryption needed, for about $22/month

RE: Team Care for 21st Century Family Medicine

, I tried responding a couple of times, but it appears I am too long winded. Here is my response in a word document.

[Guest guest]

Thanks, .

Very well thought out comments.

Locke

From: [mailto: ] On Behalf Of Brady, MDSent: Monday, January 14, 2008 8:55 AMTo: Subject: RE: Team Care for 21st Century Family Medicine

, I tried responding a couple of times, but it appears I am too long winded. Here is my response in a word document.

[Guest guest]

I

have a fortune cookie fortune taped to my monitor that reads, “J Nature, time and

patience are the three great physicians. J”

RE:

Team Care for 21st Century Family Medicine

I was taught in medical school by a wise old country doc, that if I just

listened well enough, the patients would tell me what is wrong with

them.

***Me too I thought it was a osler quote I mix two of them together

one is

iF you want to know what is wrong with the patient, ask her.

and the other is something like the job of the physcian is to amuse the

patient while nature does the healing (mangled)

[Guest guest]

Gordon and all on the listserve,

This is my first post to the listserve. I have been a respectful observer

for over a year and thank all who share experience, thoughts and reality so

freely. I offer the following with all due respect. It is an

issue about team care I have not seen addressed and one that I believe has a

lot of validity for consideration. Although not currently in clinical

practice, I worked in ambulatory care for about 25 years as an adolescent healthcare

nurse practitioner.

The issues you bring up, Gordon, about complexity, overhead, hamster wheel are

very real and I agree, at the heart of what is wrong. And to create teams

that do not clearly offer significant value to the patient, but help the

hamster go faster, are a problem.

However, to assume that only physicians, or any one type of health care

provider, can have relationships that benefit patients and can meet all

the needs of their patients around health information, navigating the health

care world, and dealing with the many issues of their lives that affect health

does not match with my experience, nor make sense from a broader

perspective. Physicians are trained in a particular way, valuable in many

respects, but see the world through that lens. Nurses are trained in a

particular model and see from that perspective; same with social workers,

physical therapists, etc.

Providers and patients have styles of relating and relate differently to the

power differences inherent in physician/patient relationships that effect

communication and interaction.

It seems to me that any good healthcare system needs now, and will need, a

variety of professionals to bring true value to all the patients that need

care. I have worked in settings where patient/physician or provider

continuity was very high, there was good access, attention was paid to culture,

information and communication. Consistently patients revealed important

information to other care team members with whom they also had relationships that

they would not talk to the provider about. In addition, I would offer

that, on the whole, other professionals are trained more appropriately to help

patients with self-management, behavior change and coping than physicians (on

the whole).

So, again, I offer this view respectfully, and with knowledge that the IMP

practices are getting better results than almost everyone else…..I think

an important issue is how to create teams that add value, serve patients and

their needs, and what mix of professionals/lay healthcare providers is

needed to balance the costs/income/complexity issues.

Again, with respect,

Cory Sevin, RN, MSN, NP

From:

[mailto: ] On Behalf Of L. Gordon

Sent: Monday, January 14, 2008 8:46 AM

To:

Subject: Re: Team Care for 21st Century Family

Medicine

What and excellent topic.

This exposes one of the most important issues facing us as we explore the root

causes of failure in the U.S. health care system as well as key aspects of

health care.

Team care is not antithetical to the IMP model. It is the opposite end of

the spectrum of the solo/solo version, but has equal claims as a hypothesis on

how to deliver effective care to achieve excellent outcomes. In the IMP

model we're defining certain behaviors (putting the patient at the center of

care, improving access & efficiency, etc) that allow us to be patient-centered

medical homes.

The problem I have with the current press and momentum behind pay for

performance and the language and measurement of the current medical home model

is that it is one--big-team-fits-all and implies (and often states explicitly)

that small & solo practices cannot be medical homes.

They state this for two reasons:

1: Solo/small practices are less likely to measure and report quality and

less likely to engage in quality improvement.

This is true.

This is due to the current misapprehension of how to measure and report

quality, based on the idea that disease and disease management defines quality

and quality improvement.

This is a false assumption.

A: Disease is important, but when we focus on disease and forget that we

treat people we miss important clues to " non-compliance " and

therefore write off significant parts of the population we serve.

True patient-centered care treats people and in doing so helps them manage

their condition(s), one of the reasons we see improved population experience of

care and clinical outcomes in IMPs.

B: Pursuit of disease management quality reporting requires significant

investment in computer infrastructure and staff time to populate data

fields. Larger organizations absorb this cost (and suffer from high

overhead and then blame the practices and then crack the productivity whip) and

have data and quality improvement staff (that drive up overhead which they pass

on to the practices, thus making the practices less financially stable, so they

crack the productivity whip again).

IMPs on the other hand use patient reported outcome measures that come at no

cost and reflect the wide base of the population they serve (thus solving the

" quantity insufficient " problem inherent in all payer/disease specific

p4p systems).

In the IMP project we show not only that solo/small practice docs are willing

to engage in quality measurement and improvement - when we have reasonable and

accessible measurement strategies/tools - but that our results are better than

those of large systems often held up as exemplars of quality measurement &

improvement.

2: The big team is the only way to achieve effective care delivery

False assumption based on the observation (and self report) that docs are too

busy to engage in effective self management support and patient centered care.

This is false because it merely addresses the symptom of the current

dysfunctional delivery system of health care in the U.S. " Because

docs in typical practices usually have to work at a pace that cannot support

effective self management support and patient-centered care, they must delegate

the work to another. "

Once again we miss the key point: Get off the hamster wheel. Stop

working at a pace that cannot support effective care.

We have data from the IMP project that demonstrates the success of this

approach.

So I seem to trash the idea of team based/delegated care. I want to make

the point again that I see team based care as part of the continuum of

hypotheses likely to be able to achieve the results we all want and need.

I worry that a large team is a difficult thing to manage. As pointed out

in an earlier post (and what we see in sports every day), excellent teams are

rare and take exceptional individuals working in ways alien to the way we are

trained.

Is the big team approach likely to achieve the results? Not until we

solve some fundamental problems:

Increased payment to primary care to support the

extra costs inherent in the big team model

Train physicians on how to be team players

(flying in the face of the selection for an inculcation of individualism

and anti-team behavior)

Use measurement strategies that reflect important

patient outcomes and not just disease

Use measurement strategies that are affordable

and accurately represent care delivery

Without these fundamental changes the big team model will

fail for the following reasons:

1: It is not truly patient-centered

As noted in the article cited as well as in the measures of success in the

NCQA's evaluation of the PC-MH, the approach is aimed at diagnosis and

treatment of disease. This misses one of the essential points of primary

care. Remember that one of the key principles of primary care is to treat

people and not just disease. The " disease management " approach

has been around for a long time and has failed to deliver the results we want

and need.

Aside from those IMPs in the project, I've yet to see more than posturing

around an empty house.

2: It fails to account for the unsupportable data burden inherent in the

measurement paradigm

3: It fails to account for 50% of the practices that a small or solo.

4: It fails to account for the vicious cycle of increasing practice

overhead inherent in the current payment and " management "

strategies. (See figure below)

Gordon

At 11:36 PM 1/13/2008, you wrote:

Interesting idea. As I

contemplated this (trying to be open minded), one thing struck me.

The article mentions:

" complete patient history for the

visit...Since this step consists of only the collection of data,

it is not essential that a physician participate... "

Ahh, but the trick is knowing what data your are

trying to collect...

I was taught in medical school by a wise old

country doc, that if I just listened well enough, the patients would tell me

what is wrong with them. I have found this to be true, and to me has much

more to do with the true " art " of healing than either the physical

exam or the decision making portion that they describe as worthy of a

physician's expertise.

Turning a physician into a healer involves the

steps they are trying to cut out of the process.

I truly enjoy the thought-provoking information

you bring to the list-serve, . Thanks.

Durango, CO

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[Guest guest]

Cory makes and excellent point, one which is supported in the

literature:

Quality of

Diabetes Care in Family Medicine Practices: Influence of

Nurse-Practitioners and Physician's Assistants

Pamela A. Ohman-Strickland, PhD; A Orzano, MD, MPH; a V.

Hudson, PhD; Leif I. Solberg, MD; Barbara DiCicco-Bloom, PhD; Dena

O'Malley, BA; Alfred F. Tallia, MD, MPH; Bijal A. Balasubramanian, MBBS,

MPH; F. Crabtree, PhD ls of Family Medicine

Jan/Feb 08

Cory makes the point that low staffing models is not the only way to the

good results and that there is a lot of literature to support team based

models. She is right.

I know that Cory is right and want to be very clear that my issue is with

the extreme teams I see proposed under some of the " Patient-Centered

Medical Home " models that postulate something like: one MD, one NP,

two or three nurses, two or three medical assistants, etc. I just

don't think that size team should become the way we all practice.

There's a lot of pressure out there from large organizations to

extinguish solo and small practices because we can't or won't engage in

measurement and quality improvement.

To that I say " nuts! " We can measure and improve

and the IMP project is demonstrating this.

I DON'T mean to imply that all practices should then become solo/small

and divest all their staff. Solo low staff practices are capable of

delivering superb care and proving it with data, so we shouldn't be

written off. The problem is that there seems to be no advocacy for

solo/small practices even though we make up 50% of the practices in the

U.S. Not only is there no advocacy for solo/small, all momentum

behind the policy I see is driven by large systems and deep pockets.

P4P and office quality measurement is being driven by organizations that

charge for their services and use strategies that are out of reach for

independent practices. Even the nominal fees and data burden of

NCQA's Bridges to Excellence program for DM are not insignificant to solo

independent practices. Practices that are then written off as

ineligible due to " quantity insufficient " which is really

a failure of the measurement approach of focusing on a minuscule portion

of the patient population and not the practice itself.

So bottom line for me is that Cory is right: team based care can

beat the pants off of usual practice, but so can solo independent

practice when it has reasonable tools for measurement (HYH) and an

accessible paradigm for improvement (IMP project) and the breathing room

to try something new and different.

As we help define a spectrum of ideal practices capable of achieving the

results we all want and need, we will likely find a wide variety of team

size, composition, and even tools. There will even be some

megateams that do a phenomenal job, but the large organizations shouldn't

hold them up as the ultimate strategy to save U.S. health care, just as

one of many potential means to the end.

We deserve a place at the table. In fact, we're leading the pack as

some of us have " patient-centered medical homes " up and running

right now while most others have merely a gleam in the eye.

Gordon

At 11:02 AM 1/15/2008, you wrote:

Gordon and all on the

listserve,

This is my first post to the listserve. I have been a respectful

observer for over a year and thank all who share experience, thoughts and

reality so freely. I offer the following with all due

respect. It is an issue about team care I have not seen addressed

and one that I believe has a lot of validity for consideration.

Although not currently in clinical practice, I worked in ambulatory care

for about 25 years as an adolescent healthcare nurse practitioner.

The issues you bring up, Gordon, about complexity, overhead, hamster

wheel are very real and I agree, at the heart of what is wrong. And

to create teams that do not clearly offer significant value to the

patient, but help the hamster go faster, are a problem.

However, to assume that only physicians, or any one type of health care

provider, can have relationships that benefit patients and can meet

all the needs of their patients around health information, navigating the

health care world, and dealing with the many issues of their lives that

affect health does not match with my experience, nor make sense from a

broader perspective. Physicians are trained in a particular way,

valuable in many respects, but see the world through that lens.

Nurses are trained in a particular model and see from that perspective;

same with social workers, physical therapists, etc.

Providers and patients have styles of relating and relate differently to

the power differences inherent in physician/patient relationships that

effect communication and interaction.

It seems to me that any good healthcare system needs now, and will need,

a variety of professionals to bring true value to all the patients that

need care. I have worked in settings where patient/physician or

provider continuity was very high, there was good access, attention was

paid to culture, information and communication. Consistently

patients revealed important information to other care team members with

whom they also had relationships that they would not talk to the provider

about. In addition, I would offer that, on the whole, other

professionals are trained more appropriately to help patients with

self-management, behavior change and coping than physicians (on the

whole).

So, again, I offer this view respectfully, and with knowledge that the

IMP practices are getting better results than almost everyone else…..I

think an important issue is how to create teams that add value, serve

patients and their needs, and what mix of professionals/lay healthcare

providers is needed to balance the costs/income/complexity

issues.

Again, with respect,

Cory Sevin, RN, MSN, NP

[Guest guest]

Thanks for your warm and engaging response! I smiled through it. I am

located just outside Boulder, Colorado.

I am not in favor of turf wars! I have been on quite a number of teams

where the various professionals really complimented one another in terms

of training, roles, personality and patient preference. I have seen

many instances where this was the case, and it brought value to the

patient and to the team members.

When teams are created for the main purpose of " optimizing " roles for

profit-this is at the heart of what is wrong with our system.

When teams are created to offer a variety of experience, training,

styles and fit with patients, the whole is greater than any one part.

And, I don't have an easy answer, because high functioning teams are

hard to create, but possible. Teams do add complexity, added costs-and

in the current payment environment, non-physicians can't really pull

their own weight $ wise.

Some things patient's need, for instance, problem solving skills, can be

done by lay health professionals. Others cannot and should not. But

the inclusion of others (lay health, promotoras, non RN case managers,

RN's in optimized roles, social workers) as appropriate offers whole

layers to patients they otherwise may not have access to......and

changes the power structure of health care delivery.......and invites

patients to the table in new ways.

The above, if done well, I would say, adds a lot of value to patients.

If not done well, often creates worse care. Given our history so far,

the " not done well " is what we are experiencing now...but that does not

negate the basic concept.

Thanks for listening!

Cory

RE: Team Care for 21st Century Family

Medicine

Hey Cory welcome!

Where are you? ( I always ask that Apparently I cannot talk to anyone

without knowing where they are:) )

You said in part:

"

However, to assume that only physicians, or any one type of health care

provider, can have relationships that benefit patients and can meet all

the needs of their patients around health information, navigating the

health care world, and dealing with the many issues of their lives that

affect health does not match with my experience, nor make sense from a

broader perspective. "

I am a former physician's assistant. (I was actually formerly a

candystriper too - what about THEIR relationship with the patient eh??)

-- The article that prompted this I think does not even say WHY the

outcome

was acheived- and the outcome was that more hgb a1 c tests( more

diabetes

process measures)- were done Process measures are not care nor patietn

outcome.They are not money or decreased liklihood of complications or

time

or efficency or continutiy.It looks like they were just measuring

whether

tests were ordered.

-- I dunno --who was saying that only physicians can have relationships

that benefit patients...

who said that?

There are a few things this all makes me thing about

1 do teams work ?

my answer sure but you have to be very very careful Teams are largely

made

up of people(humor) and people are all different and differnt people

communicate differently ( have a spouse anyone??)and the ability to keep

solid communicate parallel goals and consistncy in actions ,AND not be

borrowed by the team in the other end of the building is s difficult

2 MId levels were " invented " to extend physcnas becasue much of physicnas

work is repetive or routine( the words can vary) AS the last 30 yrs

have

gone by physciian extenders have become used to replace physicnas This

may

or may not resulst in better or worse care but as the population ages

and

has more and more complex disease it warrents caution that each kind of

provider in healthcare from an xray tech explaining that we only see

bones

not ligaments to the billing person reviewing copays to the nurse giving

immunizations etc be clear about their role

One thing I greatly fear thus took the time to respond with my

painfully

agonizingly bad typing is that provider start to split to go at it

with

each other to shift to turf wars.

Oh please no!

I am not accusing you of this but i wonder if your post comes from

being

put off or offended by others.

if nurse practitioners can talk more normal than I can, and get across

to a

patietn what dm means then ok fine good then use that np in a

reasonable

way

But in this article all they did was ordere more " process measures'

Eyes on the prize guys

and the prize is better care more effcicinelty more cost effectivley

with

better outcomes and even,p erhaps better typing. ANy way you can do

it

teams or not

Jean

[Guest guest]

Did anyone else see this editorial about an idea for health payment reform? What

do you think?

http://www.ama-assn.org/amednews/2008/01/07/edsa0107.htm

________________________________

From: on behalf of L. Gordon

Sent: Mon 1/14/2008 8:45 AM

To:

Subject: Re: Team Care for 21st Century Family Medicine

What and excellent topic.

This exposes one of the most important issues facing us as we explore the root

causes of failure in the U.S. health care system as well as key aspects of

health care.

Team care is not antithetical to the IMP model. It is the opposite end of the

spectrum of the solo/solo version, but has equal claims as a hypothesis on how

to deliver effective care to achieve excellent outcomes. In the IMP model we're

defining certain behaviors (putting the patient at the center of care, improving

access & efficiency, etc) that allow us to be patient-centered medical homes.

The problem I have with the current press and momentum behind pay for

performance and the language and measurement of the current medical home model

is that it is one--big-team-fits-all and implies (and often states explicitly)

that small & solo practices cannot be medical homes.

They state this for two reasons:

1: Solo/small practices are less likely to measure and report quality and less

likely to engage in quality improvement.

This is true.

This is due to the current misapprehension of how to measure and report quality,

based on the idea that disease and disease management defines quality and

quality improvement.

This is a false assumption.

A: Disease is important, but when we focus on disease and forget that we treat

people we miss important clues to " non-compliance " and therefore write off

significant parts of the population we serve.

True patient-centered care treats people and in doing so helps them manage their

condition(s), one of the reasons we see improved population experience of care

and clinical outcomes in IMPs.

B: Pursuit of disease management quality reporting requires significant

investment in computer infrastructure and staff time to populate data fields.

Larger organizations absorb this cost (and suffer from high overhead and then

blame the practices and then crack the productivity whip) and have data and

quality improvement staff (that drive up overhead which they pass on to the

practices, thus making the practices less financially stable, so they crack the

productivity whip again).

IMPs on the other hand use patient reported outcome measures that come at no

cost and reflect the wide base of the population they serve (thus solving the

" quantity insufficient " problem inherent in all payer/disease specific p4p

systems).

In the IMP project we show not only that solo/small practice docs are willing to

engage in quality measurement and improvement - when we have reasonable and

accessible measurement strategies/tools - but that our results are better than

those of large systems often held up as exemplars of quality measurement &

improvement.

2: The big team is the only way to achieve effective care delivery

False assumption based on the observation (and self report) that docs are too

busy to engage in effective self management support and patient centered care.

This is false because it merely addresses the symptom of the current

dysfunctional delivery system of health care in the U.S. " Because docs in

typical practices usually have to work at a pace that cannot support effective

self management support and patient-centered care, they must delegate the work

to another. "

Once again we miss the key point: Get off the hamster wheel. Stop working at a

pace that cannot support effective care.

We have data from the IMP project that demonstrates the success of this

approach.

So I seem to trash the idea of team based/delegated care. I want to make the

point again that I see team based care as part of the continuum of hypotheses

likely to be able to achieve the results we all want and need. I worry that a

large team is a difficult thing to manage. As pointed out in an earlier post

(and what we see in sports every day), excellent teams are rare and take

exceptional individuals working in ways alien to the way we are trained.

Is the big team approach likely to achieve the results? Not until we solve some

fundamental problems:

* Increased payment to primary care to support the extra costs inherent in the

big team model

* Train physicians on how to be team players (flying in the face of the

selection for an inculcation of individualism and anti-team behavior)

* Use measurement strategies that reflect important patient outcomes and not

just disease

* Use measurement strategies that are affordable and accurately represent care

delivery

Without these fundamental changes the big team model will fail for the following

reasons:

1: It is not truly patient-centered

As noted in the article cited as well as in the measures of success in the

NCQA's evaluation of the PC-MH, the approach is aimed at diagnosis and treatment

of disease. This misses one of the essential points of primary care. Remember

that one of the key principles of primary care is to treat people and not just

disease. The " disease management " approach has been around for a long time and

has failed to deliver the results we want and need.

Aside from those IMPs in the project, I've yet to see more than posturing around

an empty house.

2: It fails to account for the unsupportable data burden inherent in the

measurement paradigm

3: It fails to account for 50% of the practices that a small or solo.

4: It fails to account for the vicious cycle of increasing practice overhead

inherent in the current payment and " management " strategies. (See figure below)

Gordon

Emacs!<https://webmail.uchsc.edu/exchange/Jim.Kennedy/Drafts/RE:%20%5BPracticeim\

provement1%5D%20Team%20Care%20for%2021st%20Century%20Family%20%20Medicine.EML/1_\

multipart/52608de.jpg>

At 11:36 PM 1/13/2008, you wrote:

Interesting idea. As I contemplated this (trying to be open minded), one thing

struck me.

The article mentions:

" complete patient history for the visit...Since this step consists of only the

collection of data, it is not essential that a physician participate... "

Ahh, but the trick is knowing what data your are trying to collect...

I was taught in medical school by a wise old country doc, that if I just

listened well enough, the patients would tell me what is wrong with them. I

have found this to be true, and to me has much more to do with the true " art " of

healing than either the physical exam or the decision making portion that they

describe as worthy of a physician's expertise.

Turning a physician into a healer involves the steps they are trying to cut out

of the process.

I truly enjoy the thought-provoking information you bring to the list-serve,

. Thanks.

Durango, CO

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[Guest guest]

I predict insurance companies will get the profit from any government risk subsidies and we'll get Zip.Ben Re: [Practiceimprovemen t1] Team Care for 21st Century Family Medicine

What and excellent topic.

This exposes one of the most important issues facing us as we explore the root causes of failure in the U.S. health care system as well as key aspects of health care.

Team care is not antithetical to the IMP model. It is the opposite end of the spectrum of the solo/solo version, but has equal claims as a hypothesis on how to deliver effective care to achieve excellent outcomes. In the IMP model we're defining certain behaviors (putting the patient at the center of care, improving access & efficiency, etc) that allow us to be patient-centered medical homes.

The problem I have with the current press and momentum behind pay for performance and the language and measurement of the current medical home model is that it is one--big-team- fits-all and implies (and often states explicitly) that small & solo practices cannot be medical homes.

They state this for two reasons:

1: Solo/small practices are less likely to measure and report quality and less likely to engage in quality improvement.

This is true.

This is due to the current misapprehension of how to measure and report quality, based on the idea that disease and disease management defines quality and quality improvement.

This is a false assumption.

A: Disease is important, but when we focus on disease and forget that we treat people we miss important clues to "non-compliance" and therefore write off significant parts of the population we serve.

True patient-centered care treats people and in doing so helps them manage their condition(s) , one of the reasons we see improved population experience of care and clinical outcomes in IMPs.

B: Pursuit of disease management quality reporting requires significant investment in computer infrastructure and staff time to populate data fields. Larger organizations absorb this cost (and suffer from high overhead and then blame the practices and then crack the productivity whip) and have data and quality improvement staff (that drive up overhead which they pass on to the practices, thus making the practices less financially stable, so they crack the productivity whip again).

IMPs on the other hand use patient reported outcome measures that come at no cost and reflect the wide base of the population they serve (thus solving the "quantity insufficient" problem inherent in all payer/disease specific p4p systems).

In the IMP project we show not only that solo/small practice docs are willing to engage in quality measurement and improvement - when we have reasonable and accessible measurement strategies/tools - but that our results are better than those of large systems often held up as exemplars of quality measurement & improvement.

2: The big team is the only way to achieve effective care delivery

False assumption based on the observation (and self report) that docs are too busy to engage in effective self management support and patient centered care.

This is false because it merely addresses the symptom of the current dysfunctional delivery system of health care in the U.S. "Because docs in typical practices usually have to work at a pace that cannot support effective self management support and patient-centered care, they must delegate the work to another."

Once again we miss the key point: Get off the hamster wheel. Stop working at a pace that cannot support effective care.

We have data from the IMP project that demonstrates the success of this approach.

So I seem to trash the idea of team based/delegated care. I want to make the point again that I see team based care as part of the continuum of hypotheses likely to be able to achieve the results we all want and need. I worry that a large team is a difficult thing to manage. As pointed out in an earlier post (and what we see in sports every day), excellent teams are rare and take exceptional individuals working in ways alien to the way we are trained.

Is the big team approach likely to achieve the results? Not until we solve some fundamental problems:

* Increased payment to primary care to support the extra costs inherent in the big team model

* Train physicians on how to be team players (flying in the face of the selection for an inculcation of individualism and anti-team behavior)

* Use measurement strategies that reflect important patient outcomes and not just disease

* Use measurement strategies that are affordable and accurately represent care delivery

Without these fundamental changes the big team model will fail for the following reasons:

1: It is not truly patient-centered

As noted in the article cited as well as in the measures of success in the NCQA's evaluation of the PC-MH, the approach is aimed at diagnosis and treatment of disease. This misses one of the essential points of primary care. Remember that one of the key principles of primary care is to treat people and not just disease. The "disease management" approach has been around for a long time and has failed to deliver the results we want and need.

Aside from those IMPs in the project, I've yet to see more than posturing around an empty house.

2: It fails to account for the unsupportable data burden inherent in the measurement paradigm

3: It fails to account for 50% of the practices that a small or solo.

4: It fails to account for the vicious cycle of increasing practice overhead inherent in the current payment and "management" strategies. (See figure below)

Gordon

Emacs!<https://webmail. uchsc.edu/ exchange/ Jim.Kennedy/ Drafts/RE: %20%5BPracticeim provement1% 5D%20Team% 20Care%20for% 2021st%20Century %20Family% 20%20Medicine. EML/1_multipart/ 52608de.jpg>

At 11:36 PM 1/13/2008, you wrote:

Interesting idea. As I contemplated this (trying to be open minded), one thing struck me.

The article mentions:

"complete patient history for the visit...Since this step consists of only the collection of data, it is not essential that a physician participate. .."

Ahh, but the trick is knowing what data your are trying to collect...

I was taught in medical school by a wise old country doc, that if I just listened well enough, the patients would tell me what is wrong with them. I have found this to be true, and to me has much more to do with the true "art" of healing than either the physical exam or the decision making portion that they describe as worthy of a physician's expertise.

Turning a physician into a healer involves the steps they are trying to cut out of the process.

I truly enjoy the thought-provoking information you bring to the list-serve, . Thanks.

Durango, CO

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