**Primary Care Teamlet Formation and Evolution: Implications for Women’s Health**

**sowh-062812**

Interviewer: At this time I would like to introduce our speaker for today. We do have Dr. Hector Rodriguez presenting for us, and Dr. Rodriguez is an Associate Professor at Health Services at UCLA School of Public Health and I would like to turn over to him at this time.

Dr. Hector Rodriguez:Great. Thank you so much, and thank you everyone for joining this afternoon or morning. I am very excited to talk to you all about some projects that I have going on with respect to Teamlet formation and evolution across various contexts. 

I wanted to give a little bit about my background before we begin. I must indicate that I have a disclaimer here. I am not a women's health researcher although I am learning a lot from my colleagues at the VA Center for the Study of Healthcare Provider Behavior. Many of whom I will highlight on the next couple of slides in terms of our collaboration in this work.

So, admittedly I am not a women's health researcher although we've learned a lot in interview studies of the primary care team members undergoing transformation consistent with the Patient Centered Medical Home model including a core element which is really organizing Primary Care Professionals to have more dedicated membership on Teamlet versus sort of more having a departmental or module level organization of member roles.

And this type of transformation is really transformational for many clinics in the VA system, and women's health clinics have largely been ahead of the curve with respect to integrating mental health and social support services into clinical operations and so I think the goal really of today is to reflect on the experiences of Teamlet formation impact and other contexts so far, and how these experiences might lend insight into how women's healthcare can be organized moving forward in the VA system so this is really meant to be engaging you as experts in the area around the issue specific to women's health in the VA.

I am an Associate Professor. As mentioned and my research is only on the organizational influences on the quality of primary care, and I really I am studying teams and feedback systems in primary care. 

So, again as I stated the goals of today are really to describe Teamlet formation across three different primary care contacts. The first being the VA Healthcare System in VISN 22 where we are currently conducting a study in six practice sites who are part of the facilitated quality improvements initiative in Los Angles, San Diego and Loma Linda Medical Centers.

I have also in the thick of conducting a interview study of Teamlet changes in a private physician organization here in the greater Los Angles area, and it shows some insights about strategies that are being used in that initiative. And also I currently have a -- I lead a AHRQ funded project looking at role transformation for diabetes care in community clinics and health centers. 

Given these different implementations of team member role changes in primary care, I would like to spend the bulk of today discussing with you the important practice context differences in the implementation of primary care teamlets for women veterans. We hoped through this conversation and dialog with you that we can shape a primary care teamlet interview strategy for VA women's health moving forward.

We are really interested in understanding how sort of the PACT model interfaces with existing structures within women's health, and how we can anticipate adaptations to the model that may be necessary, so I wanted to acknowledge my close colleagues in this work. 

In the VA, I am working with Susan Stockdale, sociologist in the Center for the Study of Healthcare Provider Behavior, Karleen Giannitrapani, Alison Hamilton at Qualitative Research, so she is an Anthropologist by training, John McElroy, Becky Yano and Lisa Rubenstein. 

In terms of the physician practice, private physician organization in LA, my collaborator is Sherry Grace, and in the Federally Qualified Health Center Study, I would like to acknowledge Philip van der Wees, Mark Friedberg, Arturo Vargas-Bustamante, and Dylan Roby as core team members in the interview component of this work. 

Before we begin, I wanted to kind of assess where you are coming from. What vantage point you are coming from so that I can emphasize appropriately, so if you could take a minute to answer the following poll, am I really asking you what comes closest to describing your role with the VHA. Admittedly, I imagine this list could go on for may be 10 to 15 bullet points, and still not get this, so I had to constrain it to five options to choose what closest fits you.

In the meantime, while this poll is being conducted I wanted to acknowledge that part of this discussion today is acknowledging that there are certain assets that women's health clinics actually have before PACT initiatives. The PACT model unfolded and we should think critically about what structures and processes are in place in women's health currently in the variety of those structures and how the principles of the Teamlet model of primary care can or can't be applied to women's health.

Take an example on continuity of care, and the priorities around primary care physician continuity, also panel accountability with limited clinic operations etcetera. So, really I had like to engage you in just thinking through some of these PACT issues, and some of the work that I have done will shape, will provide some context for understanding the types of differences in modifications of implementation that may be necessary, so are we almost ready with the poll.

Interviewer:We are. You can now see the results if you would like to speak through them very quickly.

Dr. Hector Rodriguez:Great. So based on the poll results, the primary audience for this webinar, cyber seminar, are primary care clinicians and staff welcome 41%. We have 11% who are non-primary care clinicians and staff., about a quarter 23% that are management, and approximately a similar number of researchers, evaluators about 18%, and then finally about 6% organizational development and consulting. We have about a 150 participants on the call right now.

So this is helpful information. I know that the primary audience is really interested in the on the ground issues, although for the research and management audience I will kind of dovetail into implications for system change, so just in terms of setting the stage for thinking about Teamlets and role transformations in primary care, I wanted to highlight some differences in the types of restructuring of Teamlets that are I am currently studying.

And as you know, as you can probably attest in clinical practice you know some changes are much more drastic than others you know in the work in VA, VISN 22 we've realized that we went around to the primary care practices and talk to primary care stakeholders. 

It’s very clear that every practice seem to be starting at a different place with different types of resources or systems in place prior to PACT. And so PACT implementation in the Teamlet model ranges from a very drastic and transformational change in some sites, and in other sites it's sort of refining around the margins of teamlets, existing teamlets or team structures.

So, in terms of the principles of PACT reorganization in the teamlet, I think the goal, the intention here is really to structure accountability for primary care of the designated panel of patients for PCPs and Teamlets and so that, that boundary of the Teamlet really provides the majority of care for that patient, the primary care for that patient and consistent with this principle is prioritizing continuity of care with the PCP and the team.

In addition, more consistency in the working relation of the primary care personnel, so there is been a vast literature in social psychology that underscores that more consistent working relationship among team members enables the generation of codes of conduct so people understand the rules of the road, and can adjust, and be more flexible and adapt, so the principle behind this is that through fostering more consistent relationships that pattern, work pattern become more apparent, and teams are more flexible and adaptable.

And there is also recognition at prior to PACT implementation that the survey worked on  organization of VA primary care indicated lots of diverse staffing with across primary care and I think one of the thrusts of PACT implementation is to ensure a consistent level of inter-disciplinary team members to support primary care physician and nurse practitioner and PI panel. 

By contrast the implementation in the private physician organization of new teamlet roles, the integration of the new members has really focused on health coaching and nurse care management to support teamlets in chronic illness care, so it’s more focused on the chronic illness care component then sort of the general working relationship for all patients.

Similarly, in the Federally Qualified Health Center Primary Care team redesigned, they are integrating either in a cluster randomized trial community health worker or medical assistant, handle manager so that does more population management activities for diabetes care and be so its changes as you can see the nature of these changes are really different and they are having different effects on working relationships with clinicians and staff.

So I think what I would like to underscore here is that the implementation of new team member roles can be for many different reasons, and based on the capabilities of primary care clinic before implementation of the transformation really shape sort of what is prioritized in the context of implementing new role, so the PACT model of primary care depict that you know the generic model depicted in the figure you can see here.

And as you can see by my cursor with the other team membership for PACT guidance is to have a PCP, a nurse care manager, a clinical associate either in LVN or medical assistant or Health tech and a clerk support the physician's panel on a dedicated fashion.

And the thought is that the broader team members outside this teamlet would include pharmacy, social work, dietary or nutrition other case management, residence and training, and behavioral health professional. In a work in preliminary and the PACT there is been 22 interview study of teamlet members.

We realize that some clinic have drawn the boundaries around these teamlets in different ways, so for example in some clinic, for example in several of the newly, new veteran coming back from Iraq and Afghanistan, mental health has often been integrated into the Teamlet model in a more explicit way, so rather than being on the periphery of the teamlet, the behavior of, or mental health professional sort of in the center huddling with the teamlet sort of more integrated into teamlet decision making and coordination and less so, of sort of a shared practice, sort of model around these non-physician clinicians.

So in other cases for example in the -- in some clinics, nursing the integration of nursing expertise on to the teamlet was a major transformation at baseline nurse care managers, or nurses were not part of sort of the teamlet configuration or they would be involved in the direct provision of care for a designated panel of patients.

Many clinics that we have visited actually had before PACT nursing were sort of in this grave circle here where they are supporting multiple teamlets. And PACT we've seen sort of a transformation in the sense that nursing is more central. I think there were challenges with this in some ways because as you will see in slides I’ll go over later there is sometimes a tension and the appropriate integration of nursing into teamlet needs to be supported by the practicing environment.

For example, many clinics experience high walk in, and the nurses can attend to these new roles of care management with those constraints or that demand competing for their time. My point in showing this figure though is to clarify that the teamlet is really the bound of set of individuals supporting the PCP and acknowledging that sometimes the boundaries around that teamlet differ at baseline depending on the practice setting within the VA or even outside the VA.

And so many of you are women health stakeholders, and probably would draw the boundaries differently for this so, I was really interested here in your opinion about teamlet formation for women's health.

Given this model you know of teamlet configuration with this four core roles being part of the teamlet, and sort of the additional team members being on the periphery in supporting all module teamlet or a practice teamlets. I wanted to ask is the PACT Teamlet model as specified in that diagram appropriate for women veteran.

Interviewer:Thank you Dr. Rodriguez we had about 30% of our attendees respond so far, so we will leave it open for just a few more seconds.

Dr. Hector Rodriguez:  Sure. Great, so while we are waiting on those responses I must admit that you will be answering this question at the end of the seminar and my hope is that I would have challenged your thinking of it, and that may be some people will have shift their thinking about this issue.

Interviewer:Dr. Rodriguez can you see the results?

Dr. Hector Rodriguez:  I can. So to relate the results to the key role in terms of the question is the PACT model, Teamlet model appropriate for women veteran. 66% of the audience indicate yes definitely, 25 indicates yes somewhat, 8% indicates no, not really, and nobody indicated not at all as 1% indicated other.

So, in summary most of you feel that for the most part, the Teamlet model is an appropriate organization of primary care, personnel for women's health. There are women veteran. So, I think with that recognition that its primarily the audience here indicates support through for this type of change, I would like to spend most of the time talking about is what adaptation or issues need to be addressed as PACT Teamlet model unfolds more in-depths in women's healthcare, in women's health clinics, and for designated women's health providers in sites without formal women's health clinic.

I wanted to give you a bit of background to, and to show you a sort of a diverse range of key informant studies that I am conducting that kind of have provided insight into Teamlet struggles and successes. 

As you could see here, I have a chart that divides the three different types, the different projects and the three different context. The first one being the VHA VISN 22, the second thing the private physician organization and the last being the Federally Qualified Health Centers. 

The most common team members at baseline are different for each of these initiatives. The most common practice members at baseline in the VA are PCP, LVN/Health tech, RN, and as then I indicated RN often wasn't part of the core teamlet but sort of more part of the broader module, but that resource wasn’t generally available at baseline to some degree, and Clerks and MSA.

In terms of the private physician organization there is really no nursing support other than supervision in these primary care practices. They historically were smaller primary care practice sites that consolidated into larger groups, and finally the Federally Qualified Health Centers are mainly diabs PCPs and medical assistants as well, although I must acknowledged that on the periphery of that of those teams in diabs are often very, a high level of support services for that Federally Qualified Health Center populations for substance abuse treatment, mental health etcetera.

The types of role changes are really different across these, so impact teamlet transformation its really about RN population management, having a LVN’s and Health Tech uptakes, some health coaching, self-management support role in population management outreach activities, and  clerks are primarily focused on PCP panel activities versus the module activities. 

Although, we did see lots of variation so far in the implementation of clerk and health support staff are structured to support teamlet. In terms of the private physician implementation, it’s a really nurse RN care management so consistent with the PACT implementation health educator doing health coaching, and in addition to this, the private physician organization has really prioritized structured teamlet communication and what I mean by this is huddled or meetings as part of this role change.

And I know that many sites within the VHA system have tested teamlets and we actually have some insights about teamlet huddled and how effective that is they are and then perceived by clinicians and staff in the VHA. 

And finally, the safety net study really looked at the integration of new roles, completely new staff members, a community health workers, and medical assistant, panel managers who are really doing sort of population management activity.

In terms of the samples for each of these key informant studies of teamlet members, we have possibly 90 teamlet members total across six practice sites with two cohort of the three practice sites within each cohort, and for each key informant role, we within each site we selected three part-time PCPs, three full-time PCPs because we felt that the practice, the experience of PACT implementation would be very different for the part-time and full-time PCPs, three RN, three LVNs or Health tech and three clerks.

Our response rate actually was so far has been fairly high, and this fast strictness of that response so it just the indicative that we are still in the field and so we are in the midst of data collection now although I am sharing preliminary results on some level with you today.

Choices of safety-net clinics teamlet the FQHCs we are interviewing 50 total teamlet members across 14 practice sites in two ways, and generally our sampling design has been one person from each of those key roles. Interestingly, even with incentive $20 for participation in this interview we do not have high level of uptake which may be proxy for team functioning. 

We don’t know, but in the VHA we were very impressed and happy to get a 64% response rate thus far.  In the private physician organizations, we are interviewing 20 teamlet members across five sites that are implementing these two new roles of health coaching and RN care management really sampling one role from each of those five practices, and that's far we have a 75% response rate to those interviews without incentives.     

So as you could see even using similar recruitment strategies or yielding very different response rates, given the practice context and issue going on at the site. I wanted to extend, the reason why I am excited about team functioning and improving team functioning is because emerging evidence that team functioning can actually influence adaptability and capacity for change, so by if leader s facilitate team functioning in terms of establishing group norms, in terms of fostering effective inner or personal processes in terms of monitoring each others work, and having sort of intelligence, and ability to be flexible, and cross cover, and other things.  

Those types of skills, teamlet skills and team skills really enable practice participants or with clinicians and staff to undertake other transformational change because of the adaptability that kind of builds that's part of this teamlet development. 

And so I am very excited by the potential of efforts that really try to foster teamlet relationships because I think they may be the window for the VA to undergo and withstand major transformations. I wanted to show you a couple of slides here in survey works that I have done with this community clinics and health centers.  

This is a plot of the various 34 practice sites involved in this trial of integrating community health centers, community health workers, and panel manager and medical assistants. And what we saw before we implemented within interventions is that those practice sites that had high situation monitoring meaning team members sort of looked out for one another's work and there was sort of a dynamic cost covering actually had better change culture so had better experiences of changing manage, and changing managed at the site in less sort of that affects the change.

And we also saw in these patient centered medical home demonstrations around the country that adaptive reserve, this idea that in order to undertake primary care redesign practice members need to have some adaptive reserve which means the energy to orient to change. If practice members do not have that its unlikely that major structural changes like the PACT implementation were actually be successful in improving care.

So, I think there is a lot based on this cross-sectional data, there is actually some indication that fostering team development may actually have benefits for the organization in terms of capacity for change.

In terms of this interview study, I wanted to highlight that for the VHA we are really thinking about a conceptual model for under what conditions will into implementing this new roles for primary care team member actually improve patient care and patient's experiences of care. 

As you can see here in this diagram, this section right here going, moving from left to right is of the implementation of this new role is likely to improve patient center care when teamlets are appropriately structured, when teamlets function better, and that will team functioning will modify the effect of implementations within the PACT initiative, that's the hypothesis here.

And the teams’ functioning is shaped by the readiness of the organization. It need to change as well as the capabilities, structural capabilities what I mean is human resources, decision authority, authority for hiring and clerk primary care personnel, patient assistance and reminders etcetera.

And that as you can see up here clinician burnout and can actually affect readiness for change in team functioning directly in the conceptual model, and that also acknowledged here is that the quality of primary care specialty interface and bidirectional communication across these organizational boundaries is going to be even more important in the Teamlet model.

And that these conditions of highly functioning teams and a good coordination across boundaries are likely to enable improvements in patient centered care via this PACT implementation.

So just to highlight the methods that we use for this key informant interviews across the three studies are the interviews generally less than 45 minutes to an hour. We recorded all transcripts transcribed them and clean them. We got a lot of code book based on review of 16 transcripts, and are the team affected that's logic model that we just -- I just showed you in the last slide

We have asked STI to code the interview, and in during the process, this literary process of coding, we employed member check to ensure the consistency of coding between interviews so that the two coders who were doing this work actually there were some consistency checks around how that was done.

I wanted to share high level emerging results from three interview studies, and underscore the relevance to VHA women's healthcare. But this issue is importance or the differences in structured teamlet communication across implementation, so as I mentioned the private physician organization has really invested in structured communication huddled at the beginning and end of the day for every primary care teamlet, and regular meetings, monthly meetings to discuss more strategic issues as they relate to the team.

In the VHA, I will talk a bit about structured teamlet communication and some of the barriers that we saw to doing this daily. And another emerging issue especially in the VHA is teamlet member's perceptions of having incomplete teamlets, so having specific physicians not field for lengths of time. 

Third issue that emerged across this interviews is the tension between continuity of care, and access to care so patients may -- we may want to facilitate continuity with primary care physicians and the team. At the same time we know that there is a subset of patients who want quick access to care, and also that you know there is often role overload issue with PCPs needing to take walk-in and other things that impede sort of this personnel care approach.

So, the big tension on the ground that we hear about are being dinged for  a physician not seeing another physician's patients and sort of across teamlet coverage, and so that was one major tension that was emerging especially in the VHA.

In terms of coordinating coverage across clinics, one thing that we notices is that in some clinics in the VHA, teamlet members had a difficult time negotiating coverage for their teamlets across the module, across the practice because many sites did not have a formalized coverage policy.

And at other sites have really attended very well to coverage policies including you know a very transparent coverage rule in terms of identifying backup, and backups of the backups and such. So there is sort of more protocols at sites, at certain sites with respect to covering teamlet cost, teamlet coverage, and in some sites that's completely underdeveloped.

In terms of work quality and overload, what we've noticed in the VA is that some in nursing roles, some nurses on the teamlets actually have embarked on integrating population management roles, but largely we see a pattern of sort of a need on the ground to attend to immediate clinical issues like walk-in.

Turning to the leadership facilitation of the change that really differed across the interview sites. In some sites, leadership facilitation was very strong, and in some cases folks on the ground felt that there could, leadership could do more to help implementation of the new role.

Another consistent team is the utility of small test of change, so sort of this PDSA framework and how you actually effectively alter the practice structure, and we see some indication that an incremental sort of measured deliberate approach rather than a flip on the switch kind of approach have been actually results in better experience of teamlet members.

In terms of teamlet formation, the three major -- some major issues that we got surfaced in our interviews. One is that some informants expressed that they were able to influence which individuals they would be working with as teamlets, but most informants in our interviews indicated that scheduled another criteria, so having a consistent schedule or being geographically closed or other determinant, were determinants with teamlet membership, and there was high variability in the formation process across sites.

So, some sites really would deliberate and measured about assignment and others you know practice members did not feel included that process. Second, it was very clear that this is a tough transformational change for many practice stakeholders and the communication in guidance specific written guidance on how to develop primary care teamlet members role who is needed across these implementations, and this was a new unique to the VA at all.  

I think that there was a recognition things that primary care clinician staff want more guidance across all of these teamlet transformation. In terms of this being a organizational change for this difficult and complex, you know it's not just plopping a new member on to the team.

Individual roles and responsibilities need to be resorted. Norms need to be developed among teamlet members, and that is a difficult process, and that was really acknowledged in our interview.

In several of our interview sites, they trained primary care clinicians, trained residents, and operationally this was often a challenge the part-time status of many primary care clinicians in balancing the needs of residents training demand was really surfaced as an issue in this training environments, and it was less of an issue in the private sector. 

Two couple of quotes that highlight these finding. The first is development of teamlets was actually a huge change because we work a lot close to with other people in the clinic rather than its just the clerks, its just the nurses, its just the doctors, its just the practitioner indicating that the transformation was perceived as a desiloing of the operation where the resort of more cross-disciplinary communication because of the PACT transformation.   

Second and this kind of underscores the general feeling about the need to taking a measured and small test of changed approach to implementation. One informant indicated I think more of the planning came from leadership, and I think it kind of trickle down to us because it is kind of the really quick transition may be within a month or two. It's just quick. What we found that we are going to be doing this, this PACT thing.

They gave us a roof; we started meeting trying to figure out what's what. We just, we started going to the training that was talking about PACT and then we just boom put it there.

And then finally another staff member indicated a memo stating you're now on Teamlet A, B, C, D, E. Nobody knew. I think they drew names out of a hat, and put on the teamlet here you, this is your teamlet, this is your doctor, your nurse, practitioner, you are the LVN, you are the whatever, and that was your teamlet.

So, as you can see there is really a strong reaction from primary care practitioners in staff around being involved the development of this teamlets, and many felt that they were not included, and I think that in some cases you know some informants were more aware of planning processes that were going on at the leadership level, and many were not.

Another emerging thing was incomplete teamlets. And I think there is a recognition that nursing stability within primary care is the real challenge for the VA, and not a lot of providers, and a lot of LVN are having challenged with the PACT implementation because often times the teams that include the complete complement of nursing as indicated by this informant a lot of the providers, and a lot of the LVN, MSA and even RNs are complaining that the PACT model was implemented when we don’t have the proper staffing.

On any given day there is a lot of team missing their RN, so there is a perception among physicians, primary care physicians and staff that in order for the PACT model and Teamlet model to work there really needs to be a fully complement of the teamlet members. 

I think resources, another responded indicator. I think resources would be needed to make sure each teamlet is properly staffed. I think PACT model because each person has such a specific role if one person is missing the team just really falls apart, so now I want to challenge you to think about teamlet formation, and teamlet formation changes in women's healthcare many of which have already undertaken some structural changes.

I wanted to get from your opinion it's really a three part response that true or false or I guess other are hard to tell, where teamlet formation unfold diferntly for women's health clinics and designated providers, so not to influence but I think that many of you have you know a good vantage point to address this question I am really interested in some of your responses. 

Hopefully we will have time to discuss in more length. Okay so 46% indicated that women's health clinics have different practice resources so it would be true that the implementation would unfold PACT implementation, teamlet implementation would unfold differently.

Others indicated false. Almost about a little over 37% indicated false similar teamlet formation issues would be operating here, and 17% indicated that its really hard to tell at this point, so I guess there is no majority here, and as I can see this is a fairly people see this very differently and I will be interested to understand different opinions and perspectives. 

So, thanks for participating in that poll. It gives me some perspective about where you are coming from, whether you perceived this as consistent or different in the women's health contact.

In terms of teamlet individual role development in the VHA, we noticed that depending on many practices were very successful in integrating new responsibilities for nursing whereas others had challenges with integrating these new roles because of other practice demand, and so we see a high variation for each site in terms of individual teamlet members resposnbilities so in some places for example LVNs are tasks with scrubbing, and another is RNs take lead of that role scrubbing meaning proactive looking and addressing a patient needs so the next day or the next week sort of proactive management of demand.     

In terms of what we saw and many of you probably had seen presentation by Greg Stewart in the Iowa division**?** Rather than, but consistent with those findings of teamlet transformation. We will see that sometimes PCP face challenges of tasking their teamlet members because of discipline, specific reporting.

So what this means is that because primary care physicians often do not have the same reporting structure, so LVNs, and RNs report to nursing and clerks report to the medical services supervisor that often times when PCPs were given a list of to do population management activities or tasked with something to improve the care of the patients in their panel that they would often have challenges with tasking to their teamlet members because of these different reporting relationship.

In terms of, in general though based on our interview thus far we see that the RN role because of practice demand and role overload that it’s been the most challenging role to develop that part of the initiative. This quote, next quote underscores an experience here. My MSA would like for me to have full nursing everyday just like the providers, but that's impossible because who would be picking up the flack when I am doing this nursing appointments.

That box would just be full because I would be with that patient, and those providers will run light because of me, so I don't want that. And a PCP indicated though I think working with the RN to evolve that role in the care manager role that would be the biggest improvement and taking the emphasis away from managing and triaging lock ends, to really managing panel of patients. The different skill set is more case management which is very different moving a triage nurse.

Another informant indicated for example some of the other teamlets be LVN though with all those scrubbing. For me, my LVN says it's too much work for her, so I am helping her three days a week. She does two days a week. In terms of the reorganization one thing that became clear is that the structuring of primary care into PACT model, the Teamlet model really uncovers individual effort so when the allocation of work is done at a clinic level, when many clinic members are responsible often times accountability is a little harder to track and so one informant highlighted the change in uncovering differences and effort by one of the biggest complaints I see with the PACT now is that a lot of older employees are refusing to change, and these are the employees that have been with the VA for 10 years or longer.

And so this people we are used to other people picking up the slack because everything was done in one bunch. Nobody really got it -- nothing, nobody really got accounted for what they were doing, and so the idea here from this informant and several other informants is that because the PACT makes it very apparent what your role is for a specific designated panel that if there is slacking or limited effort by one person it becomes more obvious to the other teamlet members than it was in a module level organization.

The main resounding theme and I think this goes across context is that the PACT primary care clinician teams what meaningful training in terms of more concrete guidance how to implement the role. I think lots of trainings have emphasized other issues like the team communication or specific strategies like huddling or scrubbing.

But folks really want to know more about specifics about delineation of roles, and sort of coverage and flexibility in those issues and how to do that. So, this informant indicates that specifically what people's roles need to be in the teamlet process need to be more clear because there is you know people who aren't aware what the clerk is able to do, what the RN is supposed to be doing. 

I think if there was some kind of training, well not even necessarily training, but just something that you could specify that people in the teamlet should be doing rather than passing it off to whomever. This came out over and over again, so what concrete guidance about role development?

I am going to share this quote with you, as I mentioned one strategy is teamlet huddles, and the private physician organization is really prioritizing this as part of their teamlet transformation, and one quote I really like about teamlet communication or team communication generally is this one how about much attention we give to team's development in the real world. 

It is not easy to think that to bring together a highly diverse group of people and expect that by calling them a team they will in fact behave at the team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the two hours on Sunday afternoon when their work really counts,

Teams and organizations seldom spend two hours per year practicing when their ability to function of a team counts 40 hours a week, and so part of this team development in terms of facilitating team communication many have thought about structured communication or huddled over or team meetings.

The idea is that structured communication is really important for implementing these role changes. This electronic information and communication may not be conducive to the adoption of new roles which you know lower level staff need to ask questions and feel confident, and electronic communication maybe doesn’t achieve that. 

It is important to develop a teaching and learning environment, and way to foster that is through a structured communication. The objective of the huddle have been in this primary physician organization implementation are really to plan for daily tasks and roles to review any facilitators of the arrears of the days work, to reflect on the previous days work what went well, what didn’t work so well so, but and to identifying developed solutions for adjusting systematic problems. 

So, I wanted to ask you or the half of the seminar participants that our primary care clinician staff do you daily, huddle daily with your teamlet or team. And in our experience in the VHA may be I hope I don’t change your answer, but I because of part time schedules and other things, huddles are often challenging. And there is many adaptations of that daily huddle that we have seen in primary care clinics.

So, interestingly uprising to me most 43% of poll participants indicated that yes usually they huddle daily with their team. Yes sometimes was 24%. Nobody was unsure. 24% or about a quarter indicated that they do huddle, but not, but pretty infrequently, and 9% or less than 1 in 10 indicated that that never really happens, so it looks like the adoption of some sort of structured communication is actually among you all is, it is, its happening here whether it would be a formal daily huddle and the adaptation of that. In the physician organization will skip the details, but essentially as part of the team role, transformation that really is shooting this huddle is part of the core component. It’s a brief daily checking among teamlet members, lasts for about 5 to 10 minutes, and generally prior to morning and afternoon patient appointment. 

And the agenda content is generally divided into four different sections. One is review which is workload and operational status issues, identification which is scheduling changes, preparation which is discussion of special needs of patients and processes for example may be disabled patients or heart appearing patients, or other patients may be with psychosocial problems and growth, so this is the one I wanted to underscore is growth. 

As I mentioned to develop these new roles for nursing and for you know other non-physician teamlet members, it's really important that there is these some vehicle for in-person communication, and this implementation that’s really one of the purposes here. 

And I wanted to, many times I get ask who should set the agenda, in my view it’s the most organized team member should take this on and as part of this it's clear that even in organizations where there is discipline specific reporting where nurses report to nursing and clerks report to medical services support leads.

It’s clear that PCP’s Primary Care Physicians and Providers need to develop mentorship skills, and facilitate the learning process as part of this. And may be department managers and this implementation are really playing a critical role, and in fact with the round on the huddle you know based on the day of the week so on Monday they will morning, they will huddle with team, team with X, in the afternoon they will huddle with team of Y, so that there are some interface with broader clinical decision making for the operation.

In terms of structured communication for the VA, we know that huddles are routinely implemented. And this is largely you know the daily huddle that's implemented, but we see lots of variations. The most common variations we’ve uncovered is informal meeting between the two members like the PCP, and the LVN for example. 

One thing that we did note specific to the VA is that in some sites, instant messaging is perceived to be a leaner form of communication than in-person meetings especially for teamlet communication between clinics encountered. And I wanted to ask you all are huddles or structured communication, daily with teamlet is really essential?   ****

One responded indicated that we use instant messaging which is I think the best because before whenever I need to talk to the provider or nurses, I have to look for them everywhere. I was be like going in a circle just to find them, but now since with instant messaging it's so convenient. The patient needs lab, the patient needs medications, medical refill, and I get the in answer right away, and they will do it right then and there. 

So I wanted a segway into this final couple of minutes, and I'm sorry, I didn’t have more time to had the vote here, is you know the women's health applications, and in terms of you know the development issues for women's health it's clear from Becky Yono, and other women's health researchers that women's health clinics have diverse organization skillful services because of local patient volume, clinical expertise available in primary care and the capacity with the new organizations. 

We hope to develop and expand our teamlets development studies to women's healthcare. And we aimed to understand how women's healthcare teamlet is formed, how they function, how they affect staff member roles and responsibilities, how they interface with non-teamlet members in primary care, how they affect the women's veteran's experience of care. 

I wanted to ask you though how effective do you think teamlet hurdles are as a team communication improvement in strategy for VHA women's health care. You perceive them as being very effective, somewhat effective, not effective, or ineffective, somewhat ineffective or ineffective?

Interviewer:Okay it looks like the response have stopped rolling in, so just over 56%, around 56% say very effective, 33% say somewhat effective, 3% not effective or ineffective, 6% some way ineffective, and 2% ineffective.

Dr. Hector Rodriguez:  The way I mean so I get the sense from the audience that structured -- it's resonating that structured communication can be owed some benefits although there is tensions on the ground, and operationally we had to make this work.

I wanted to just say I'm sorry again I wanted to focus more on this, but I got too excited with other things. So I would love your feedback by email, or anywhere you would like to communicate to me, but me, and my team have talked about some differences in women's health that we would like you to reflect on. 

One is the limited women's health clinic operations at some sites may make achieving this continuity measures, and performance measures especially challenging. Many VHA women's clinics are pretty small, and so we are organizing Canada's model level like the team like rather than the module been efficient and effective way for providing in a professional care to women veterans, so in small sites with a handful of clinicians primary care, providers in women's health, does it make sense to either further narrow that team composition to team. 

At works sites with high proportions of walk-ins, how do you handle the daily workload of women's health providers when they have limited capacity to handle same day triage and referral?  Women veteran's also on average are more likely to need supportive services and specialty services. So this information transfer and care coordination across the boundaries of primary care, and outside the VHA are even more salient for improving the care of women veteran's than in the general veteran population. 

And also to explain the difference in women's health development, teamlet development is that given the wide range of health services used by women veterans, departmental or service agreements when you know to delineate accountability between departments will be even more important as VHA women's health improvement implements the PACT teamlet model. 

So of my final poll question to you is you know given these different the context of implementing PACT in women's health limited operations, the kind of more psychosocial needs of women veteran, what is the most important operation or strategic issue to consider when implementing the PACT model for women veterans of the Teamlet model. Is it that how to balance PCP continuity in access to care, that social workers, mental health etcetera are already part [Technical Difficulty] be part. Is it the part type status of many providers; is it care coordination or something else?

Interviewer:Thank you. We do still have some answers streaming in, but I'm going to go ahead and start to read the general results. Just over a 1/3 say had about PCP continuity and excessive care around 20% social workers mental health etcetera part of the teamlet 20% the part time status in many women health PCPs, 25% care coordination across organizational boundaries, and 6% report other. Thank you to those respondents.

Dr. Hector Rodriguez:Thank you. As you can see there is very diverse use of what the major challenges will or the most important issue, but I think what this really highlights is that there are special issues of implementing PACT in women's health that need to be attended too proactively. And I think one of the benefits of having the interview study early on in teamlet implementation in women's health is to shape and provide guidance to leadership around what sort of adaptations will be necessary. 

So, that I wanted to end with the final poll-question to see if I changed any thinking in this seminar. Will the PACT Teamlet model work for women veteran?  Yes with some modifications to tailoring or no. And I know anything mean by limiting your choices.

Interviewer:Thank you. We do have answers streaming in, and they do vary quite a bit now. So currently about 1% are saying no. About almost 60% are reporting yes, and right around 40% are saying with some modifications or tailoring.

Dr. Hector Rodriguez: Great, well I think with this -- I hope I stimulated your thinking about the implementation of PACT in women's health, and how the experiences about other teamlet implementations can inform the proactive adaptation or tailoring of PACT implementations for women's veterans. I think it's clear based on our, my discussions and a collaboration with women's health researchers here in LA that those assets in women's health before PACT that need to be a recognized, and considered an asset in this implementation of the Teamlet model, so thank you very much for your time. 

Is there a way to get questions?  If you need to -- if you would like to contact me or provide your insights or feedback I would love to hear them. My email is hrod@ucla.edu.

Interviewer:Thank you very much. We do have some questions coming in. Okay. I apologize for this screen. Let's go back. Okay, so we do have some questions that have come in, and we will go ahead and get to those right now. 

The first one that came in and I do understand that we have reached the top of the hour, and don’t worry we will address as many questions as we can get to. This is referring back to towards the beginning of the session. Where do you see specialty care located in the circles such as cardiology or provider seen outside the VA such as private practitioners? 

Dr. Hector Rodriguez:That’s a great question. In my conception, they would be may be even on the periphery of the module members. I think that there is definitely been an emerging literature on the specialties, specialist role especially for patients that require routine follow-up from the specialist, so and specialty clinics are being a medical home.

For example, at services like OB/GYN or services like that require ongoing care like endocrinology where patients establish more sort of continuance relationships with clinicians. I assess that there may be a role for specialist as you know leaves in the medical home. In terms of the interface with them, I think what's recognized in our interviews we did ask clinicians and staff about specialty interface. 

And largely the PACT implementation doesn't seem to be at least directly affecting that, although I think what we've recognized is that there is different depending on the site and PCP. There is a different process for interface. At some sites, nursing takes a larger role, and in some sites it's completely up to the PCP to have that communication and follow-up. 

So I think we have a lot to learn in terms of the best interface and best practices in interface with specialty care. And there is a diverse range of models that my personal opinion is that they are really on the periphery of this team unless it's the specialty that has ongoing sort of relationships.

Interviewer:Thank you for that response. We actually only do have six remaining questions if you have time to stay and capture them on the recording. If not, we can get written responses out to the attendees. 

Dr. Hector Rodriguez: Sure I could stay on.

Interviewer: Great, thank you. What prompted the non-VA organizations to initiate these role changes?

Dr. Hector Rodriguez: So I think there is recognition in every stakeholder, every organization I have worked with that the primary care shortage, physician shortage is not going to go away even with intensive reform in terms of medical training reform, and incentives to go in the primary care. 

And that as Ed Wagner have eloquently put it to me a team who -- inter-disciplinary primary care teams are non-optional at this point. And so I think there is a recognition that the pragmatic issues of primary care physicians apply.

The benefit issue in terms of patients care though is that physicians are strong in many dimensions of patient care of course, but those who are trained in specifically around health education or mental health clearly have a different role in patient care in given the complex, the increase to get complexed profile of primary care patients. 

It's really important to have this expertise readily available, and the physician really can't do that. So I think, A there is a recognition that, and challenge with recruitment in primary care physicians, and burnout among primary care physicians, and that they need to be supported better. 

Also there is writing on the wall with healthcare reform that these sorts of models of care are going to be incentivised and actually promoted in terms of reimbursement and that sort of things down the road, so investments now well reap benefits later.

Interviewer: Thank you for that response. This next question came in early on in the presentation you referenced a wave, what is a wave?

Dr. Hector Rodriguez: Sorry so just to clarify when I'm saying wave I mean you know number of interviews, so for one cohort for the VHA cohort with those 90 members, 45 members are part of the first cohort, and 45 teamlet members are part of the second cohort. Each of those cohorts have two interviews, and each interview is characterized with a wave, so sorry for that language there.

Interviewer:   Thank you very much for that response. The next question, could you speak to the level of integration of mental health with the primary care clinics?

Dr. Hector Rodriguez:  Yeah, certainly I think what we've recognized in PACT is primary care mental health integration you know the great work by Lisa Rubenstein, Jackie Fickel, and others at the VHA, Center for the Study of Healthcare Provider Behavior actually done implementation studies of primary care mental health integration, and the organizational factors that kind of promote the integration. 

I think one thing that is clear in these Teamlet interviews is that based on need, need factor seem to drive the integration. So for example, for the Iraq and Afghanistan newly returned veterans because PTSD and other mental health challenges are very common in that population for those clinics that specialized in serving that segment of the veteran population actually had taken more effort to integrate social work and mental health on to the primary care team even including them in huddles, and in team meetings, and in another formal structures.     ****

When there is less of a need in general for the patient populations, there doesn’t seem to be as much integration. I think I differ to doctors Rubinstein and Fickel about the specifics in terms of organizational facilitators, but in terms of the teamlet transformation we see that it is unfolding diferntly the integration based on need.

Interviewer: Thank you for that response. The next question, did you study I am sorry, I think this was supposed to say did your study address the challenges of CBOC staff completing the huddles?  It is difficult for the Teamlet to meet at the same time, the PCP and the LPN meet regularly, but the RN is already doing triage and the clerk is checking inpatients.    

Dr. Hector Rodriguez:  Yeah. Actually this is very common. I don’t think it's specific to CBOCs either. I think schedule you know given that many VA physicians actually have multiple diverse responsibilities research and other administrative responsibilities in clinical, and I think that the part-time status and coordination of scheduling has been a really challenging logistical issue for routine huddles. Although with that said I think that clinics that are faced with this constraint actually have adopted and developed other ways of communicating that.

They perceived to be just as effective. For example, weekly huddles for example with a larger complement of the team, or using instant messaging throughout the day to communicate and then as needed, and as possible having a more formal huddle. So, I guess the jury is out there, there is a little empirical research assessing the effect of doing huddles, and I think that this is something that requires further study in terms of whether adaptations of the huddle, does it really need to be daily, does it really -- all communication need to be face-to-face etcetera.

So I certainly see this unfolding diferntly and it doesn’t seem to be specific to CBOC versus medical center, and it's driven by scheduling challenges that many face across the VA.

Interviewer: Thank you for that response. The next question we have in regards to 'Adaptive Reserve' and energy to orient change. Do we have a good Teamlet tool to measure these qualities overtime as PACT evolves serial measuring of Teamlet health seems key?

Dr. Hector Rodriguez:Yeah. There is an emerging literature on Adaptive Reserve. It's really the Transfer Med, medical home demonstrations as well as the AHRQ medical office survey on patient safety is the ambulatory care version of clinician and staff survey.  I have actually some good measures that a lot of it said Adaptive Reserve. Adaptive reserve is multi-dimensional and multi-construct, and it's experienced-based, so it's not eliciting perspective, but more sort of what has happened in the past, and I believe the Transfer Med initiative has -- that's where that measure stems from

But I think there is more validation clearly needed in the assessment of do these actually predict you know outcomes of the transformation like improved patients or veteran's experiences. So now I think that there is instruments developing, there needs to be a bit more assessment of whether they’re  useful for managing change or transformation though I think that it is a great idea using clinician and staff surveys to as a barometer for you know capacity for change. I do think that it requires further study to see how useful that is so.

Interviewer: Thank you for that response. As we continue going people keep asking questions. Are you still available?

Dr. Hector Rodriguez: I am yes. This is fun by the way.   

Interviewer: Thank you so much. Well, the audience truly appreciates getting to have the live interaction with you. The next question, what did you say scrubbing referred to?

Dr. Hector Rodriguez:  Oh Yes. This is something that it has been fairly institutionalized that at least in our VISN 22, and I believe it was part of PACT training for many. Scheduled scrubbing is essentially and its often done in different time horizons, but the most common implementation of scrubbing has been LVN, working with their physician to identify patients that are coming in like the next day or the next week that either could be managed proactively via telephone like they really don’t need a visit or that preparation can be done in anticipation of their visit including labs or imaging studies or other things, so that, so visit is actually a more proactive encounter with the patient and that visits aren't the primary way of addressing patients concerns that you know there is sort of a more proactive outreach to see if the PCP can address some of the issues that maybe able to do, done by phone in a more timely manner.

Interviewer: Are you aware of any reduction of hospitalizations or ER visits in VHA as a result of PACT implementation for about two years?   

Dr. Hector Rodriguez: I know some have been studying it. And I have to differ to this individual to about the results because I think they are in precedent. I don’t feel right disclosing that, but the VHA Economic Research Group in Palo Alto, Dr. Jean Yoon and her colleagues have actually conducted a study of ambulatory care-sensitive hospitalizations and looked at that, and I believe that's under review, but definitely Dr. Jean Yoon is leading that effort, and I think she would welcome questions.

Interviewer: Thank you. We have three comments, and I will get through them real quick. One was that one of the poll questions should have had an N/A category because those of us in management don’t work on PACT teams directly so I just didn’t answer it. I don’t know if other people may have said no or never, but it might skew your results. So, we appreciate that comment on although we are aware that these are rough estimations I guess.

Would you like to comment?

Dr. Hector Rodriguez:Yeah I am not publishing these results, but thank you. Its funny seems like a -

I think I may have said clinicians and staff at the beginning, but good point, never might be excited because of some non-clinical responses, yeah.

Interviewer: Thank you and the other comment have just been the many, many thanks people are downloading your slides, left, right, and center, and everybody really appreciates the content of this talk. You did a wonderful job. So they wanted me to pass along my thanks and to those us for the remaining which is a large portion of the audience. Please do convey your thanks to Dr. Rodriguez as you exit the session you in a few seconds, a survey will load on to your web browser, so please take a moment to just answer those of your questions, and provide some feedback. We do take your comments into account, and with that I would like to offer you a chance to say any concluding comments Dr. Rodriguez?     

Dr. Hector Rodriguez: It's been a pleasure, and I had a lot fun. You guys asked some really great questions, and its clear that there is high consequences to women's health for implementing this model in an effective way, and so we are really interested, me and my team in your perspectives on the ground, and in management with this reorganization, and what we should be looking out for as we embark on interview studies in women's health.

Interviewer: Thank you again for your time, and that does formally concludes today's HSR&D presentation. We are getting questions about will the session be repeated?  No, but we have recorded the entire thing, and you will receive a follow-up email with a direct link to the recording, so thank you for your inquiry.

And with that thanks again Dr. Rodriguez and everyone have a lovely day.

Dr. Hector Rodriguez:Bye.

[End of Audio]

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