March 5, 2015 | Tags: Blog | Tags: Interview , Team Based Care , Clinician Vitality
Amireh Ghorob, MPH is currently working with several Oregon practices on improving access to care through the PCPCH model through a Learning Collaborative led by CareOregon (read more about the Collaborative in another Institute blog post “Six Practices Working to Improve Access and Patient-Centered Care”). Amireh is a health care transformation and redesign expert and the principal consultant for Hand in Hand Health Solutions.
Most recently, as the Director of Training, she spent five years at the Center for Excellence in Primary Care at the University of California San Francisco, where she was able to contribute to important models that contextualize medical home transformation, including The 10 Building Blocks of High Performing Primary Care and Share the Care, the latter of which the Institute interviewed Amireh to discuss.
What is Share the Care?
It is so many things – it is a culture, a method, an approach, and a mindset. It means looking intentionally at the needs of your patient population and creating a team to meet those needs. Share the Care puts the patient first and encourages practices to be daring and creative in delivering patient-focused care using a team-based approach.
What does it look like in practice?
Dramatically different than how many practices deliver health care today. Currently, it is common for the physician to do much more than they can or need to do. Share the Care is a paradigm shift from the lone-physician model, where team members are not practicing at the top of their license, to a team-based approach using MAs and RNs in a more meaningful way. In practices where Share the Care is embraced, patients are more satisfied, non-clinicians participate in delivering meaningful patient care enabling physicians to spend more time doing work only they can do, and staff and clinicians experience more joy at work.
What does Share the Care mean for practicing physicians? And for those entering medical school?For those practicing now, it requires trusting other team members and a willingness to relinquish some degree of control in order to share responsibility of their patient panel with a team. At first, this may be a challenging task. It means asking physicians to train and mentor team members and be more engaged in overall quality improvement efforts at their site. We know many physicians are overworked because it’s impossible for one person to provide all the acute, preventive and chronic care for an entire patient panel. Preparing for Share the Care may seem like one more responsibility, however, the long-lasting rewards justify the initial effort- more team members to care for patients, more meaningful face time with patients and increased satisfaction at work.
Share the Care may be one solution to address the primary care shortage. Medical students may be more drawn to primary care if we are able to provide positive clinical experiences showcasing effective team-based care. Some medical schools have expanded curriculum to expose future clinicians to Share the Care. For example, UCSF has trained first year medical students in health coaching, a proven chronic care model.
What does Share the Care mean for Medical Assistants?Doing different work, and early on, it means doing work outside of their comfort zone. In Share the Care, MAs take ownership over certain parts of both preventive care and chronic care. MAs become more active and believe “these are my patients too.” MAs take the lead for communications like scrubbing charts and huddling. Too often, Share the Care is described as delegating or “offloading” from physicians to MAs. It isn’t about that – those carry a negative connotation, like work is being dumped from one role to another. We advocate for empowering MAs to deliver meaningful care in a way that is better for patients and for clinical operations. Share the Care is an opportunity for MAs and physicians to work more closely together towards better care of patients.
The article really emphasizes standing orders – what suggestions do you have for implementing these?
First they should be written by the clinicians and the leadership of the practice together so there is clinic-wide buy-in. The standing orders must be meaningful enough to actually Share the Care. For instance, a standing order that only permits a nurse to separate abnormal from normal labs doesn’t close a care gap. This order doesn’t empower the nonclinician team member to execute an action that results in meaningful care. And this leads to bottlenecks - waiting for a physician to sign off on routine tasks. Standing orders should improve flow and eliminate bottlenecks so patients may receive timely care.
Some clinics have used standing orders to eliminate bottlenecks for medication refills. Many times clinics are clogged with calls or walk-ins about refills, and often they are routine. In those cases, based on protocol and up-to-date labs, medications can be refilled until the next appointment. If the standing orders are very clear about the required lab values and an appointment is scheduled, then a nurse or medical assistant could authorize the refill.
There are many private practices who believe this is valuable for large practices or community health centers. How have you seen this work in independent practices? And what about small practices with fewer resources?
Actually, small practices have inherent advantages owing to their size. I think about it like this - a large practice is like a basketball team and a small practice is like playing doubles tennis. With a larger team you have more people to organize under one mission, increased possibility for communication errors and more opportunities to drop the ball. Changing larger teams is like turning a cruise ship. On the other hand, improvement, change and communication on smaller teams can happen more nimbly, like turning a fishing boat.
The struggle for some small practices is reaching the tipping point since even one person presenting resistance can seem like a monumental barrier. Imagine one doubles tennis partner refusing to hit the ball. To overcome this challenge, a new culture must be intentionally grown with more input and consensus from all members using frequent check-ins and one-on-one conversations.
Even though small practices feel like they don’t have the staff or space to implement certain improvements, and that might be true, they do have the advantage of testing creative change in a more agile environment.
What is the best way to challenge those who are resistant to Sharing the Care?
I wouldn’t challenge them – I would engage them! We have conversations about what it is, how it works, and what it could mean for them. Change is scary and I would want to know what they are nervous about and figure out how we can alleviate their fears while making progress.
If primary care leaders read one article or book on team-based care, what should it be?
I highly recommend Switch: How to Change Things When Change Is Hard by Chip and Dan Heath.
What advice do you have for practices struggling with team-based care?
You are not alone, in fact, you are in good company! Clinics successfully implementing team-based care have struggled for years to overcome challenges and change their culture. Furthermore, these clinics know that there is no end to the process. The improvement effort is on-going but hopefully less exhausting as the desired culture, protocols and processes are in place. It takes time, conversations and relentlessness. Be patient. Stay positive.
The best advice is to visit a site that is doing team-based care successfully so you can see it in action!
Kate Elliott is the program director for the Patient-Centered Primary Care Institute, managed by the Oregon Health Care Quality Corporation.