High Functioning Teams Can Mean Less Physician and Staff Burnout
The evidence related to high functioning teams reveals the benefits to everyone on the team when physicians take the facilitative rather than the directing approach. Rachael Willard-Grace and her colleagues (2014) looked at the relationship of team structure and culture to burnout or emotional exhaustion for both primary care clinicians and support staff. “Team structure” in their study indicated the consistency with which the same primary care clinicians and support staff worked together. They called a small group that worked together on a regular basis a “teamlet.” They used the term “team culture” to describe what might be called the cohesion of the team, built on elements such as: communication, participation, effort, social support, respect and shared objectives (essentially the IOM list of the elements of a good team in the “Quality Chasm” report). The study was done in 16 primary care practices, 10 serving primarily low income or uninsured patients and 6 serving more commercially insured and Medicare patients, in total encompassing 264,000 visits in the year before the study. They found that a strong team culture seemed to protect against emotional exhaustion for both clinicians and support staff. Tight team structure and consistency of working as a team helped to promote team culture, particularly for the physicians, and team culture lowered stress and increased work satisfaction for everyone.
Willard-Grace, R., Hessler, D., Rogers, E. Dube’, K., Bodenheimer, T., and Grumbach, K. (2014). Team structure and culture are associated with lower burnout in primary care. JABFM, 27:229-238.
Many health professionals have been surprised at how their patients have taken to telemedicine. The loss of the physical presence of the doctor, at least for many, has been more than made up for by the convenience and autonomy that telemedicine offers. The challenge for the future of medical care for a large portion of the medical services that will be provided is not how to get back to face-to-face medicine, but how to utilize a broader array of our tools for caring for people through the new medium. There are tons of start-ups trying to make cheap and convenient ways to reporting bodily functions at a distance. Yet the most widely used form of exchanging medical information is through talking, and the most important medical channel is the relationship between the patient and the health professional.
There is one population of patients that will require us to be particularly innovative in how we use the medium of telemedicine. It is the population of “multiply-disadvantaged” patients.[1] These are patients who, in other literatures, are called “complex” patients because of their burdens of multiple chronic illnesses and behavioral health problems. They tend to use a disproportionate number of medical services, though in many cases those services still don’t address their needs adequately. These patients have very high rates of trauma as children or adults. They are likely to be “dually disadvantaged” because of their low incomes and because of the racism or bias they face as members of minorities.
This population of people is likely to be suspicious of medical providers and to resent what they have experienced as disrespectful care. Paradoxically, they are much more likely to follow suggestions for taking care of their health when they have developed a trusting relationship with a medical or behavioral health provider. Evidence produced by programs that have had good outcomes serving multiply-disadvantaged patients shows that they need “high touch” care (see “High-Touch Telemedicine”) provided by high-functioning primary care teams that include a medical provider, a behavioral health clinician, and a care manager or health coach. The health coach keeps the relationship between the patient and team current, while monitoring the patient’s condition and progress. For these patients, “patient-centered care” has been shown to be most effective when it is transparent (patients have access to all their medical information and notes) and empowering (the care focuses of the strengths of the patient) so that the patient can be a partner in developing their own care plan. The challenge in serving this population through telemedicine is how to enact this patient-centered approach to team-based care within the limits of the medium.
I am currently working on a project funded by the HRSA Graduate Psychology Education program through Antioch University in New England to create a video example of one patient visit that enacts team-based patient-centered care. The product the project will be the video of the visit and an accompanying webinar that describes the ideas and principles that the video will exemplify.
I would be interested in hearing from primary care professionals, both medical and behavioral, who feel that their setting has developed innovative ways of giving patients the experience of patient-centered care by high-functioning teams using telemedicine as the central (but not necessarily the only) means of contact between the team and each patient. I can be contacted at ablountedd(at)gmail.com. Also see: www.IntegratgedPrimaryCare.com
[1] Blount, A. (2019). “When the doctor-patient divide is a chasm,” Patient-Centered Primary Care: Getting from Good to Great, Springer, 77-92.
Abstract for Chapter 2: From a Squad to a Team: Creating Team-Based Care
The transition to team-based care within primary care is a foundational step in building an environment that promotes relationships between patients and clinicians that are truly patient-centered. Changing from an individual provider with staff support to a team is the first step in the change in “mental models of care” called for by the evaluators of the National Demonstration Program. The change can be characterized as a change from a squad to a team. It is a transition from a small group that is hierarchical with an unchanging leader to a group with greater participation among team members and flexibility in leadership. This change gives greater flexibility in the delivery of the services that make a difference to patients. It has been shown to lead to an improvement in group cohesion, improved patient satisfaction, improved quality of services, and lower burnout for both clinicians and support staff. Making such a change is not easy. One requirement is the dedication of time for team meetings, both daily and weekly, that is commensurate with the importance of the team’s successful functioning to the delivery of care. For these to be effective, the team needs consistency of membership. https://link.springer.com/book/10.1007/978-3-030-17645-7
Abstract for Chapter 3: Behavioral Health and Care Enhancement: Building a Team to Do the Whole Job
For practices that are attempting to develop patient-centered team-based care, the addition of one or more behavioral health clinicians (BHC) is a logical step along the way. When done well, adding a behavioral health clinician enhances the fit of the expertise of the team to the needs of many of its patients. Behavioral health care within the primary care practice greatly increases access for patients by being a better fit to their understanding of their needs and therefore increasing its acceptability. The patterns of communication among team members that make for successful team-based care are the same ones that make for successful integration of a behavioral health clinician. The expertise that is added to the team by a behavioral health clinician can help to foster the change in “mental models of care” that has been discussed as underlying the transition to both patient-centered and team-based primary care. In addition, for the patient with significant challenges in the area of the “social determinants of health,” a team member who is able to enhance the care provided by the team, sometimes called a navigator, care manager, case manager, or community health worker is also a crucial part of an effective team.
ACT.md, selected for American Society of Clinical Oncology Interoperability Demonstration
Healthcare has seen a number of efforts to realize interoperability for health data. We believe that such a vision is still at least 3-5 years away from meaningful application. However, emerging standards such as FHIR and initiatives such as SMART and the Argonaut Project are very promising in being successful and accelerating the timeline to realize these goals.
In the next three weeks, I’ll be providing some updates specific to ACT.md and our involvement and commitment to these important efforts. ACT.md was built from the ground up for team-based care and while integration isn’t necessary in order to realize value quickly, we were architected from the start to easily work with others. Our service is a platform-independent HTML5 web application built on top of a REST API, allowing us to integrate and partner with other healthcare technologies and organizations to provide healthcare teams, patients, and caregivers what they need to drive the best care possible.
On Monday, June 1st at the American Society of Clinical Oncology’s Annual Meeting, ACT.md will demonstrate our ability to develop a collaborative and patient-friendly care plan and send it directly into the Epic Electronic Medical Record.
ACT.md was selected to participate in ASCO’s first Interoperability Demonstration because of our unique approach: connecting all members of the care team, facilitating safe and reliable hand-offs, providing a space for collaborative care planning, and involving the patient and their family in a way they’ve never experienced. For the first time, the patient AND their family/caregiver understand who is on their dynamic care team, what everyone’s roles and responsibilities are, and what activities associated with their care plan (medical and non-medical) need to take place and when they should take place. Their goals are reflected, and they have a way to communicate with their care team in a structured, asynchronous fashion.
Our Chief Medical Information Officer, Dr. Narath Carlile, and our Director of Sales and Marketing, Christina Strubbe, will be at the Annual Meeting, "Illumination and Innovation", to drive this demonstration. They will also be available to talk with oncology leaders about how to support team-based care models including the CMS Oncology Care Model (OCM) and Oncology Patient Centered Medical Home (OPCMH). I encourage you to reach out to engage in a discussion about emerging care models and interoperability.
Learn more about other participants in the ASCO Interoperability Demonstration and ACT.md's ability to share the care plan across care settings.
Getting paid for coordinating care - what does the primary care provider need to do?
Guest post by Narath Carlile MD MPH, CMO and CIO, and Betsy Nicoletti
With the 2015 Final Physician Fee Schedule released on Halloween (they seem to love releasing rules on holidays), CMS has introduced non-visit-based payment for chronic care management (CCM). Despite its modest potential rate (0.61 RVUs, or approximately $40 per patient in a calendar month), this structural shift is arguably “the most important broadly applicable change it has made to primary care payment to date.”
We all know that patients with comorbid conditions can't and don't get all the care they need in a 30 minute office visit. Finally, physicians can get paid for the coordination work between visits. Here’s how to make it a reality.
What is it?
The new CPT code (99490) allows physicians to bill for 20 or more minutes that their staff spends on non-visit-based care coordination activities each month for their Medicare patients.
So what?
Quality care requires a lot of coordination work between visits, and usually this responsibility falls on the primary care provider. Since coordination is not a visit or procedure, it has not been reimbursed in the past. Many providers, of course, already coordinate their patients’ care because it is the right and necessary thing to do for positive outcomes—however, it comes at a cost to their practice. The new CPT code can help to offset some of that cost. Now, reimbursement is in-line with realistic workflow and quality.
The bottom line: “A physician caring for 200 qualifying patients could see additional revenue of roughly $100,000 annually.”
How is it done?
In order to bill for this code the following conditions must apply to the patient:
Patient requires at least 20 minutes per calendar month of clinical staff time coordinating care or communicating with the patient (under general—not direct—supervision)
Patient suffers from 2+ chronic conditions expected to last at least 12 months or until patient’s death
The chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
Additionally, the practice must meet the following requirements:
Use a certified EHR (which includes 2011 or 2014 certifications that meet the core technology requirements)
Offer 24/7 access to clinicians (who have access to the care plan) to handle urgent care needs
Maintain a designated practitioner for each patient
Regarding the care plan:
The physician must collaborate with the patient to develop a comprehensive care plan that is accessible to the care team 24/7 — however, this does not have to be created or transmitted by the EHR, and could be fulfilled more effectively by a platform that is designed to create and share a care plan amongst the whole team caring for a patient
The electronic care plan should facilitate caring for the patient during transitions
Notably, it must be possible to share this care plan digitally with the patient and external providers (including community providers) and the patient needs to have web based access to this as well
Care management includes assessment of the patient’s medical, functional and psychosocial needs.
And the patient will need to do the following:
Consent (annually) to you providing CCM services
Pay the copay for each month you bill for CCM services, approximately $8. (Of note, many patients will have secondary insurance which will cover this.)
Really, how is it done?
Many foresee the major stumbling block being tracking the time spent on between-visit work across multiple team members and easily reporting this so appropriate billing can be done. Some electronic platforms for team-based care coordination can make this very easy.
For many PCMH’s (or practices in the process of becoming one), most of the requirements can be met with the simple addition of an electronic team-based care-planning tool like ACT.md.
Is anyone taking this on in January?
Yes, and you should take advantage of it immediately! ACT.md is already working with practices who have successfully billed for Transitional Care Management (TCM). Toni Apgar, RN, is a care coordinator at one of these practices. “CCM as outlined by CMS is, at its root, simply good patient care,” she said. “We have been providing this kind of care planning and follow up to our chronically ill patients for some time. We find med management especially critical to a patient’s long-term success, along with establishing a personal relationship between care coordinator and patient. We are pleased that CMS is recognizing the hard work this represents between patient visits, and the positive effect on patient outcomes. We hope other payers do the same.”
To claim your coordination reimbursement, we recommend you do these things immediately: First, identify patients that qualify. Second, educate patients and obtain their consent in advance. Third, take another look at your EMR’s functionality to see what it can already do to support this. Fourth, determine how to create a patient-centered care plan based on your usual procedures. Finally, identify a way for the entire care team, including the patient and caregiver, to communicate and execute effectively on that care plan.
Bringing A Management Model To Healthcare: Team-Based Care
Guest post by Ted Quinn, CEO and Co-Founder, originally posted on Forbes
Early in my career I worked in management consulting with healthcare technology clients. We structured our engagements as a team of professionals with diversified skills, focusing on a strategic question facing a client’s business or operation. As a team, we worked to harness available data to analyze and formulate a set of recommendations to address this question. An Engagement Manager led projects, having overall responsibility for the development and execution of the plan including resourcing, budget, timeline, and deliverables.
In order to execute the plan, each project team member (including the client) had to clearly understand his or her role and their deliverables. At the end of the day, we were hired because the team executed a plan that led to the desired results and exceeded the expectations of our client. The single uniting factor I’ve seen repeatedly across a range of industries and professions is this: high functioning teams are central to success. What if healthcare had the same structure and accountability with Team-based Care? How do we support the physician or care manager who is often charged as the “engagement manager” for the patient?
Healthcare has an opportunity to apply the team-based models of other professions to the job of patient care. As business theorist Clayton Christensen defines, “The jobs-to-be-done framework is a tool for evaluating the circumstances that arise in customers’ lives. Customers rarely make buying decisions around what the ‘average’ customer in their category may do . . . [rather] because they find themselves with a problem they would like to solve.” Both patients and professionals involved in the care of patients have told me “I just want someone to tell me what I need to do.” Patients want to understand how to get better and physicians want to do what they came into this profession for – to deliver quality care and help people. Delivering on this job requires that providers and patients employ principles of Team-based Care.
Patients Are Like Projects
What if we thought of patient care as we do projects in other professional settings? These team-based projects would have diverse team members, tasks, plans, and objectives. As in management consulting, the patient project information would be available to all members of the team (in this case, the patient, caregiver, doctors and other healthcare professionals). At any point in time, all members of the team would quickly understand the state-of-play and know how to communicate to drive action. This is Team-based Care. This new care delivery model would help healthcare realize the quadruple aim of care: enhancing patient experience, improving population health, reducing costs, and improving the work life of clinicians and their staff. As I heard from an Oncology center in New England, “when we implemented a Team-based Care delivery model, accompanied by a patient-centered project management tool we reduced the time spent on coordination and communication activities by 30%.” Team-based Care can quickly yield measurable results.
Four Requirements for a Successful Team-Based Healthcare Delivery Model
Requirement 1: Metrics and Visibility to Measure & Improve
New models of care are driven by health quality metrics. To collect this data, organizations have invested in electronic medical records, health information exchanges and population health tools for the purposes of documentation, billing, aggregating data, identifying high-cost populations, and tracking quality metrics. These investments have led to provider dissatisfaction, staff burnout, and patient frustration as all parties are burdened with tasks often detached from care. In a 2014 survey, 68% of family physicians and 73% of general internists said they would not choose the same specialty if they could start their careers anew. As one physician noted, “I can’t believe how much of my time is now spent documenting instead of executing care!” The team-based project model of care would help improve care processes for everyone involved – creating greater efficiencies and higher quality.
In consulting, we always knew the status of the project. Questions such as, “Are we executing against the plan? Are all members of the team meeting their commitments? Are we on schedule, on budget, and meeting the goals of the client?” could quickly be answered. This data enabled the manager to measure, adjust, and improve team performance to meet commitments. Likewise, Team-based Care would provide new data (e.g., execution to plan, team composition, team loading, patient engagement, etc.) for the healthcare provider and their patients. Such analytics would empower organizations to implement continuous improvement initiatives to refine how care is happening. Knowing the state of play and being able to make adjustments in real-time is critical to delivering reliable healthcare.
Requirement 2: Know the Team
One of the first tasks in launching a consulting project is for the manager to find the best professionals available to study the strategic question of the client. Typically team members were from different offices, had never worked together, and had to quickly understand their unique responsibilities. In a Team-based Care model, all participants similarly understand the composition of the patient’s team. I have a great deal of sympathy for healthcare providers working in today’s environment. There seems to be an ever-increasing range of process pressures, relationships to manage, and technology challenges. A typical primary care physician must coordinate with 229 other physicians across 117 practices. And we see the results: 40% of all malpractice claimsinvolve underlying communications problems.
A large pediatric practice here in New England illustrates the challenge of team complexity. This practice hired a care coordinator to work with the most complex kids within their practice. The coordinator needs to work with various pediatricians, social workers, nurses, community resources, and a range of specialists to provide the best care possible to the child and family. Once a month this team of healthcare professionals meets in person to discuss the plan and define responsibilities. At the end of the meeting the team disperses with few means to communicate, no way to understand what’s happening in real time, and little visibility into the process of care. Handoff drops are commonplace because no one understands if tasks are completed and require dependencies addressed. It’s only when the team reassembles that they fully understand what did or did not happen, and are able to reset the plan. Kristy Trask, an RN who manages involved cases like these recently stated, “As a care coordinator for kids with complex needs, I need tools to work across all the players supporting the family and child.” Healthcare needs better tools for patient management.
Outside of healthcare, it would be extremely rare for professionals to be without support by the appropriate information technology to manage projects as complex as a sick child. Yet, even in the 21st Century, most healthcare professionals do not have the project management and communication tools to handle a single patient – much less a portfolio of 3,000. Patients often choose their own doctors and specialists. Therefore, different care team members may not know each other, may not have worked together previously, or communicate with each other regularly if at all. In a true Team-based Care model, clinicians, staff, patients, and caregivers could have the ability to know who is on the team, everyone’s role and responsibilities, and interact with each other to move care forward.
Requirement 3: Know the Plan
In management consulting, the central responsibility of the Engagement Manager is to facilitate communication and ensure efficient project execution. In Team-based Care, communicating the plan – including coordinating key activities and identifying responsible owners – is a requirement. With patients moving between different healthcare organizations, communication and coordination presents as a significant obstacle. This is complicated by the fact that health information technology is complex, sensitive, and siloed with little opportunity for easy access and implementation.
Requirement 4: Patient-Centered and Patient-Involved
The core job-to-be-done of healthcare is to help individual patients get better and enjoy the best quality of life as they manage their health. The core job-to-be-done of Team-based Care is to keep the patient and their needs at the forefront. Teams must be mapped around a patient. There must be real-time accountability to the status of the patient’s health. Patients and caregivers should be given visibility to (1) know who is on their team (2) know what the plan is – in a way they can understand and (3) know the current state of play.
The Power of Team-based Care
Earlier this year my PCP retired after 18+ years of providing me with outstanding care. It was interesting to hear him describe how the regulatory, contracting, and technology changes underway in healthcare were contributing to his decision to hang up his white coat and stethoscope. So much of what’s being asked of physicians and nurses has little to do with why they pursued a career in healthcare. We need to reduce the complex demands placed on healthcare professionals and simplify how clinicians work to deliver on the job of healthcare. The adoption of Team-based Care represents a path to engage all patient stakeholders in a simple and more cost effective model of care.
