Getting Practical on Teamlet

Management of Workload, 

Continuity, and Access:

An Exercise in 

Three Dimensional Thinking

Lisa V. Rubenstein, MD, MSPH

VA Greater Los Angeles, UCLA & RAND

7/11/2012
VISN 22 VAIL Leadership

VAIL PRINCIPAL INVESTIGATOR

Lisa Rubenstein, MD, MSPH, Overall

EVALUATION LEADERSHIP 

Elizabeth Yano, PhD

INTERVENTION LEADERSHIP

Lisa Altman, MD, Greater Los Angeles 

Philip Roos, MD, Loma Linda

Timothy Dresselhaus, MD, MPH, San Diego

Justin Sivill, MHA, VISN22

Susan Vivell, PhD

PROJECT DIRECTOR

Susan Stockdale, PhD

CONSULTANT

Jim Jackson, RN, V20

VAIL STEERING COMMITTEE 

Skye McDougall, PhD, Chair

Donna Beiter, RN, MSN

Marianne Davis, MPH, MLS

Laura Dolata, MSN, FNP-BC

Rebecca Feria, RN, MSN

David Gray, PharmD, FASHP

Cheryl Hardcastle, BS

Peter Hauser, MD

Michael Kilmer, MSW

Donald Moore, RPh, MBA

Randy Quinton, MS

Mark Rielo, MA, MPH

Sandra Robertson, RN, MSN

Robert Smith, MD

7/11/2012 VAIL-PACT VISN22 2
• Capacity & workload—How many patients can be 

cared for? 

• Continuity—seeing the same provider over time

– Strong evidence for improved cost & quality

– Highly valued by patients with chronic disease

– Less valued by healthy, younger patients 

compared to access

• Access—getting visits when needed

– Strong relationship to patient satisfaction

Managing Clinical Work to Achieve 

PACT Goals 
• How many of you are based in sites that 

A. Have adequate staffing capacity for 

providing PACT care

B. Meet access goals

C. Meet continuity goals

D. Have achieved all three

Poll
• The ―sweet spot‖ is an intersection of 

capacity/workload, continuity and access

The PACT Compass Shows the 

Parts, But Not the Relationships 
Capacity

• Site level 

• Individual provider
• A work in progress

–Use with caution

–The Site A example is hypothetical 

combines information from several sites

• Aim is to create tools to assist sites

–Feedback is welcome

Disclaimers
• In PCMM, identify the number of primary care 

patients

• In DSS, identify the proportion of primary care 

face to face time for each provider

• At 1200 patients per panel, calculate needed 

PCP, teamlet & team FTEE for PACT care

Capacity Step #1: Is My Site’s Staffing 

Approximately Adequate for PACT?

Provider Name DSS Clinical Time

Provider #1 .5 FTEE

Provider #2 1.0 FTEE
• Site A has 

–16,000 patients in its population

–Needs e.g., 

• 13 PCP FTEE

• 13 -15 each RN, LVN, clerk for 

teamlets

• 4 - 8 teamlet pharmacists 

• 2 team social workers

Example: Capacity for Site A
This academic site has

• 18 individual MD/NP/PAs at 11 FTEE; needs 

13 FTEE

–5 NPs work .1 to .7 clinical time

–6 MDs work .1 to .6 clinical time

• 10 RNs & 12 LVNs at 10 FTEE each; needs 

15 FTEE (to assure coverage) 

• 1 social worker at 1 FTEE; needs 2

Staffing deficits are a known major cause 

of teamlet dysfunction

Site A PACT Staffing & Deficits
• Reevaluated and renegotiated PCP ―nonclinical‖ paid time

–Surveyed PCP’s regarding time allocation for 

specific committees, research, teaching, QI

–Identified e.g. low priority committees, 

unfunded research, QI without approvals

–Renegotiated clinical time transparently & 

changed values in DSS

–Hired one new PCP

Site A Approach: PCP Sufficiency
• Reviewed ALL site functions and ALL staff vs work

–Specialty clinic volume, activities

–Procedure location and support

–Patient information, greeting, MyHealtheVet

• Identified duplicated, untargeted, low use activities, 

e.g.

–Low volume specialty clinics could be combined, 

releasing RNs, LVNs, pharmacist & social worker

–RN procedure support, e.g., conscious sedation, 

duplicated & could be combined 

Site A Approach: Team/Teamlet Sufficiency 
• Evidence review shows equal or greater patient 

satisfaction for part-time PCPs 

–Teamlet structure can enable part time PCPs to 

achieve PACT goals

• Higher coordination demands on clinics generated 

by part-time PCPs & housestaff may be offset 

–These PCPs can bring leadership, research, 

education, or QI into the PC environment

• Efficient and effective use of time in clinic must be 

achieved to justify part-time practice, however

Site A Approach: Support High Quality 

PCP’s With .1 to .6 FTEE Clinical Time
• Reviewed ALL site functions and ALL staff vs work

–Specialty clinic volume, activities

–Procedure location and support

–Patient information, greeting, MyHealtheVet

• Identified duplicated, untargeted, low use activities, 

e.g.

–Low volume specialty clinics could be combined, 

releasing RNs, LVNs, pharmacist & social worker

–RN procedure support, e.g., conscious sedation, 

duplicated & could be combined 

Site A Approach: Team/Teamlet Sufficiency 
• Overall site capacity was in the ball park for 

PACT with redistribution and limited hiring

–Shifting/consolidation of jobs inside & 

outside of primary care based on careful 

analysis

–PCP time was allocated fairly and 

transparently, including part time PCPs

• Enabling coverage for missing teamlet RNs 

& LVNs was a priority

Site A Capacity: Conclusions 
ACCESS
• Match expected to actual available PCP visit time 

(Jim Jackson/Justin Sivill formulas) 

• Expected supply based on each teamlet/provider’s

– DSS clinical time, bookable PC hours per week 

(minus e.g. wound clinic)

– Patients per hour when in PC clinic

• Actual supply based on evaluation of clinic 

schedules (grids)

– Weeks per year in clinic

– Cancellation rates, panel attrition rate, continuity, 

return visit rate, patient sicknesss/complexity

Fine Tuning Supply and Demand
• Definition: bookable appointment time is 

negotiated DSS clinical time using the 

formula (% clinical PC visit time x 40 

hours) x .9. 

–Equates to 28.8 bookable hours per week 

for clinicians with 80% clinical time.

Supply: Simplified Calculation
• Variations in 

–teamlet/provider return visit rates

• Sometimes accounted for by variations 

in panel sickness, especially mental 

health 

• Also affected by discontinuity, rates of 

non face to face encounters

–available grid time per year for same 

clinical FTEE (e.g., due to travel, teaching)

Example Site A Supply Findings
• Review teamlet scheduling grids, panel size, 

attrition, no-shows, patient complexity, return 

visit rate and identify outlying values

• Review available teamlet PCP clinic visit slots 

per week and per year and adjust expectations

• Set a realistic panel size goal for each provider

–Adjust expected panel size based on return 

visit rate if justified by complexity level

Site A Approach: Working With 

PCPs and Teamlets
• For Open Access

–Aim for 30% to 50% of slots unbooked at the 

start of a workday

–This reflects a judgment that 50% to 70% of 

slots should be pre-booked follow-ups 

(internal demand)

–Scheduling method may require adjustment 

for part-time clinical PCPs

–Emphasize non face to face and teamlet

supported interactions to reduce return visit 

frequency

Site A Approach: Open Access
• Open access generally means open access to 

the continuity teamlet and PCP

–Having some slots available for walk-ins to 

non-continuity providers is necessary

• Use of non-continuity walk-in slots must be 

minimized to hit the continuity/access ―sweet 

spot‖

–Ensure access to someone to reduce ED 

visits, improve satisfaction

–Maximize decision-making by the continuity 

PCP through teamlet continuity management

Open Access and Continuity
Continuity:

It’s easy to achieve continuity if you don’t 

care about access, and easy to achieve 

access if you don’t care about continuity 
Continuity, Access and Walk-ins

• Increasing one can worsen the others

• Improvement requires intensive focus on

–Telephone answering, pharmacy refills

–Post discharge & post-ED follow-up

–Scheduling, including resident/attending

–Use of non-face to face visits
• Teamlet report card

–Can drill down to individual discontinuity 

visits

• Walk-in reduction

–Pharmacy refill and expiration generated 

50% of walk-in visits

–Engaging teamlets & pharmacists 

reduced walk-ins for refills to 20%

• Changed schedules for residents 

Site A Continuity Interventions
BLUE

PCMM Panel Continuity with 

Provider

PCMM ED 

Encounters

PCMM Phone 

Encounters

Numerator

Denominator

% 

Continuity Numerator % ED Numerator % Phone 

May Team 

Summary 



654 782 83.6% 55 7.0% 131 20.0%

June 1-15 

Summary 



347 399 87.0% 29 7.0% 66 19.0%

June 1-15 

Detail 

Blue 1A 46 56 82.1% 8

14.3% 36.5%

Blue 1B 71 78 91.0% 3

3.8% 11 15.5%

Teamlet Report Card*

*Programmed in SQL to generate up to date results
50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

DEC-FY11 APR-FY11 AUG-FY11 NOV-FY11 FEB-FY12

PACT Measure: PCP Continuity

Site B Site A

Site C Site D
• The whole process falls apart if

–Teamlet is dysfunctional

–Scheduling system is too rigid or too loose

–Schedulers are free to put non-continuity 

patients into open slots

–There is no good system for walk-ins

–Teamlets function inequitably

• Bottom line: If teamlets do not function, 

AND/OR do not back each other up, patients 

are at risk

Lesson Learned: It Takes a Village
Open Access, Continuity, and 

Capacity—A 3-Dimmensional Puzzle
Characterizing Primary Care Provider Activity 

in Routine Practice

Steven C. Marcus, Ph.D

Philadelphia VAMC 

Center for Health Equity Research and Promotion

Center for Evaluation of Patient Aligned Care Teams

University of Pennsylvania School of Social Policy and Practice

marcuss@upenn.edu

Christian Terwiesch, Ph.D

Andrew M. Heller Professor at The Wharton School

terwiesch@wharton.upenn.edu
Understand primary care provider roles and activities during 

patient encounters and explore opportunities for productivity 

improvement in care teams.

1. What types of care occurs during patient provider 

interactions?

2. Who could be providing this care? 

3. Could the care occur off-site?

Overview
Video taping “day in the life” of primary care provider at PVAMC. 

1. Characterize the full range of activities that occur during the 

encounter and quantify the amount of time used in each one. 

2. Characterize the encounter by having physicians quantify the 

amount of time in each visit that could be done remotely or 

by an extender. 

3. Describe physician judgment of appropriate time to next 

follow-up appointment.

Methodology
Male, 59, here for a primary care follow-up visit. Last PC visit was 5 

months ago. Patient had been hospitalized due to numbness in the legs 

and inability to walk or talk. His blood sugar was 500 and he was started 

on insulin. His blood sugar had spiked due to poor diabetic dietary 

adherence (eating candy and soda), but was 225 at the time of the last 

visit. 

Progress note for current PC visit indicates that his diabetes may be “too 

tightly controlled, given that he is taking his long acting insulin as if it 

were short acting insulin,” putting him at risk of overdosing on insulin. 

Provider gave patient’s wife, who administers the medication to him 

based on his glucometer reading, instructions on how to properly 

administer the medication. Provider also set patient up with pharmacy 

diabetes management clinic for insulin management and education.

A Typical PCP Patient
Example of a Timed Video Encounter 
Analysis 1: What Type of Activities are Performed?

1. Small Talk

2. Discussing Existing Condition

3. Discuss New Conditions

4. Medication Review

5. Treatment Plan-Med

6. Treatment Plan-Other

7. Examine Patients

8. Health Promotion and 

Disease Prevention

9. Coordination of Care

10. Write Visit Notes

11. Interruption

12. Other

We examined 21 encounters from 5 PVAMC PCPs for specific 

activities which we grouped into 12 categories.
Analysis 1: Time Spent on Various Activities

* Based on 32 patient encounters from 9 providers at PVAMC

0:00:00

0:00:43

0:01:26

0:02:10

0:02:53

0:03:36

0:04:19

Time spent During A PCP Visit
Analysis 2: Redesigning Care Delivery

Care is provided by

Doctor Extender

Onsite

Remotely

Status quo

Emails and follow-up calls

Example: “Do you want to come in 

for your follow-up 

appointment or talk on the 

phone?”

PCP extender calls

Example: “do you need refills

of certain medications?”

PCP extender onsite

Example: patient education,

discuss weight loss

Presently, all activities (time) was spent by Doctors onsite (upper left cell)

Opportunity to redistribute

From Providers to Extenders

From Onsite to Remote
As before, using the videos 

broken up into “episodes”

Each episode categorized to:

- onsite / off-site

- provider vs. extender

Analysis 2: Redesigning Care Delivery Process
Analysis 2: Methodology

Classification is based on subjective evaluations done by three physicians

Physicians were instructed to use their clinical judgment to categorize into one of the four cells

In the case of disagreement (2:1), we assigned activity to cell based on majority vote
Analysis 2: Results

Care is provided by

Doctor Extender Total

Onsite 19% 3% 22%

Offsite 59% 18% 78%

Total 78% 21% 100%

21% of the work could be done by an extender: 78% of the work could be done off-site

* Based on 9 encounters from 7 providers
Analysis 3: When Should We See This Patient Again?

• Our analysis assumed that the visit had to happen – but why is 

the patient in the office today?

• In most cases, an appointment was made several months ago

• Revisit frequency is critical for panel sizing / doctor’s capacity

• Objective: how do physicians determine the time to the next 

appointment?
Analysis 3: Agreement on Revisit Frequency: 

When Should We See This Patient Again?

When should we see this patient again (in [months], response by three PCPs)?

Large disagreement among physicians

Future research: How does revisit frequency change with new primary care work-flow 

(expanded care team, off-site communication)
Future Work / Next Steps 

• Increase sample size

• Compare these results across sites (PACT 

and non-PACT)
Thanks

Rachel Werner

Jennifer Gutierrez

Mary Pelak

Debashree Sengupta

Lindsay Jubelt

Shreya Kangovi

Jeff Kullgren