A Team-Based Approach to Primary Care
It’s a clunky term for a simple, yet revolutionary idea: “the patient-centered medical home.”
In a U.S. health care system that’s often fragmented and costly for the consumer, this approach is streamlining primary care by treating the whole person with a collaborative team.
Since the passage of the Affordable Care Act, primary care has been receiving a lot more scrutiny. In many cases across the nation, the health care system hasn’t been providing the most effective or efficient care.
“We’ve had to do a bit of soul-searching in primary care because we weren’t delivering the goods very well,” said Kevin Grumbach, MD, chair of UCSF’s Department of Family and Community Medicine and co-director of the UCSF Center for Excellence in Primary Care.
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“It was hard to get appointments, and we weren’t meeting all the patients’ needs, especially if you look at diabetes care and rates of preventative cancer screening,” he said. “It’s not enough to just say we need to try harder; we need to rethink the system. So that’s behind this push to rethink what the roles of people are on the provider team.”
Increasingly, studies suggest that a more team-based approach to care could be a big part of the solution. UC San Francisco research has been key in showing the effectiveness and cost-efficiency of the “patient-centered medical home,” and in driving implementation of this model in multiple centers at San Francisco General Hospital.
Instead of the primary care physician trying to do everything in a 20-minute appointment, a whole team of health care providers is responsible for the patient’s care – from nurses to doctors to community health workers to mental health specialists to pharmacists. The team works together to anticipate the patient’s needs, communicate their findings with each other, and make sure no aspect of the patient’s health slips through the cracks.
Kevin Grumbach, MD
From the patient’s perspective, it’s a one-stop shopping experience: In a single doctor’s visit, a patient could receive treatment from his or her primary care doctor, do a preventative screening with a nurse and a technician, and visit with a mental health specialist. In this approach, more is more – but it actually costs less.
A 2014 study by the Patient-Centered Primary Care Collaborative, a national coalition of health care providers and other supporters of the medical home concept, found that this model decreased health care costs by about 60 percent, in large part by reducing the number of emergency visits.
An Idea Born from Problem-Solving
The patient-centered medical home isn’t a new idea.
The concept originally arose from caring for children with chronic illnesses; these patients and their families often see multiple physicians, have complex treatment plans and require myriad tests. So before seeing the day’s patients that day, the doctors, nurses, mental health specialists, medical assistants and pharmacists would huddle to discuss any upcoming needs.
Kimberlee Honda poses with a young patient at SFGH.
The Pediatric Asthma Clinic at SFGH has been using this team-based approach for over a decade.
On a recent morning, Kimberlee Honda, FNP, director of the Pediatric Asthma Clinic held a brief huddle with her team, including behavioral health specialists, a nutritionist, nurse practitioners, community health workers and social workers.
One community health worker brought up a concern about a young patient coming in later that day: He’s living in a house with significant triggers like dust and mold.
If an environmental issue like old carpet is suspected, the clinic would send a community health worker to the child’s home to evaluate. The clinic could help the family write a letter asking the landlord to change out the carpet, or even issue a letter directly. The providers can also involve a team lawyer if they need to escalate the situation.
“We have to treat asthma in context. If something is going on in the family or the home setting, we make sure it’s addressed first,” said Honda.
The team also has social workers who can help families address other needs, and education specialists who can advocate for students with special needs, including attending parent-teacher meetings at school.
Click on the image to view a larger version.
Treating all aspects of a patient’s health is a key part of patient-centered medical homes. Just down the street, primary care providers at SFGH’s Family Health Center are moving toward this model.
About a year ago, the providers fully incorporated behavioral health specialists onto the team, which has been a “breakthrough,” Grumbach said. For example, he said, if he had a patient who was depressed, her son was in a gang and her husband was drinking, “there was usually this sense of ‘oh my goodness, I have 20 minutes, how am I going to begin to address this?’”
Now he can bring the patient down the hall to talk with a therapist on the spot. This lets Grumbach spend his time treating the patient’s health issues he’s trained for, and rely on other team members to handle issues in their area of expertise.
Teaching Teamwork for Better Health Care
Health care providers go through intensive training to become a pharmacist, dentist, social worker or physical therapist. But training to work on a health care team? Not so much.
"There’s a big push for interprofessional collaboration, but historically we haven't trained students to work in this environment. That's why we've been developing this course,” said Angel Chen, RN, MSN, CPNP, and vice chair of UCSF’s Department of Family Health Care Nursing.
UCSF has created the first online interprofessional course for health professional students around the globe to prepare the next generation of care providers.
The course, which begins Sept. 15 through Coursera, covers five areas vital to the team game plan: collaboration, team roles, communication, conflict management and negotiation and leadership and team membership.
Letting All Providers Shine
That’s another strength of the team-based model: It allows everyone on the team from pharmacists to medical assistants to nurses to perform to the fullest capacity of their training.
This is especially true for nurses, who are highly trained in patient care and other specialties.
“The team-based approach provides roles for nurses for which they are uniquely prepared. The approach is highly collaborative and requires excellent communication skills on the part of all the team members,” said Kathy Dracup, RN, PhD, dean emeritus of the UCSF School of Nursing.
“The patient-centered medical home provides a role for nurse practitioners in caring for patients who have a relatively stable chronic disease, but still need routine care and attention.”
Shonul Jain, MD, director of SFGH’s Children’s Health Center, says the nurse’s role is particularly important in implementing team-based cared in an academic setting, in which a team may include some physicians who are only in the clinic for one day a week because they also teach and do research. Having nurses on the team helps provide critical consistency of care.
“The patient is owned by the whole team – it’s not just the primary care physician’s patient; it’s our patient. So the idea behind the patient-centered medical home is to really give the nurses more of a role in patient care management,” said Jain.
That consistency and care comes across to both providers and patients alike.
Treating the Whole Patient
Margo Vener, MD, says after 20 years of working at the Family Health Center, now with the team-based model, she really relies on her coworkers.
“It used to be that you would just work with whatever staff person happened to be here that day,” Vener said. “You often didn’t know their names, and patients didn’t either. Patients would say ‘oh, I saw that nice lady with glasses last time.’”
Guadalupe Lisea, a medical evaluations assistant, discusses her patients for the day with Brigitte Watkins, resident, and the team at the Family Health Center. Photo by Elisabeth Fall
But now, she said, “I feel I can put more trust in a team, because the team brings all sorts of things to a clinical encounter that I don’t know.”
And while the patients certainly don’t know the term “patient-centered medical home,” she said, “what they do know is when they come in, they always see Isella. If they have a question between visits, they call her. If their appointment isn’t right, they call Grace.”
While her clinic mainly treats the urban underserved, Vener says the patient-centered medical home is a good model for providing care for everyone.
“The human connection makes a difference in helping patients feel cared for. It’s not just a system. That’s the team part. They feel like they’ve got a family here.”
Top photo: The green team at the Family Health Center at San Francisco General Hospital discusses their approach for the patients coming in that afternoon. From left to right: Guadalupe Lisea, medical evaluations assistant; Elizabeth Uy-Smith, MD, MPH; Steven Chang, resident; Brianna Stein, resident; Margo Vener, MD; John Nhieu Dang, medical evaluations assistant; Tiffany Cheuk, medical social worker; Karen Duong, medical evaluations assistant; and Leslie Suen, resident. Photo by Elisabeth Fall