Interval examination: building primary care teams in an urban academic teaching clinic.

After designing the team structure, we defined the roles of each member. The medical home committee met for 6 months to identify the clinic’s tasks and match the right work to the right person. We eliminated duplicative or inefficient duties, creating space for team members to take on expanded roles. For example, MAs now review patient records to identify healthcare maintenance gaps using the electronic health record (EHR). Though we had implemented standing orders for routine cancer screening, immunizations, and diabetic foot monofilament exams two years prior, they were not being completed consistently. With the MAs, we mapped out their healthcare maintenance workflows and found that hectic clinic flow was the major barrier. We reorganized MA schedules to provide each MA with 4 hours per week of dedicated chart preparation time and they are now consistently able to review patient records prior to clinic to identify healthcare maintenance gaps. As another example, team clerks make appointment confirmation calls to patients, which has resulted in a 30 % reduction in the clinic no-show rate. When we initially proposed confirmation calls, clerical staff expressed concern about being able to handle this new task. We eliminated less critical duties such as extraneous paperwork, creating space for them to take on this expanded role. After training the clerks with written telephone scripts, they are now more comfortable calling patients. Our patient advisory board members have declared our confirmation calls “the best thing that’s happened to GMC in years.” GMC patients have a high burden of psychosocial as well as medical complexity, and coordinating their care often overwhelmed part-time providers. To address these challenges, we did two things. First, we integrated behavioral health onto our care teams. Each team has one behavioral health clinician—a licensed clinical social worker or psychologist—who is co-located in clinic. We reconfigured the roles of these existing staff to be team-based: they attend daily huddles to discuss behavioral health needs of scheduled patients; take warm hand-offs, meaning they meet with patients during provider visits, as well as schedule independent follow-up visits; and are available for consultation about behavioral health needs of team patients. Integrating behavioral health has allowed team members to communicate and address patients’ psychosocial needs in a more coordinated manner. Second, we developed a complex care management team. Led by a registered nurse, this interdisciplinary team works intensively to decrease admissions and emergency department (ED) visits for our most frequently admitted patients. The team supports part-time providers by caring for patients between visits and focusing on time-intensive tasks such as self-management support. Patients in the program have 49 % fewer inpatient hospital days (9.6 to 4.9 days/patient/year) and 21 % fewer ED visits (3.4 to 2.7 visits/patient/year) compared to the year prior. Despite these successes, redefining roles requires a continual juggling of responsibilities. One ongoing issue is the high volume of patients who drop-in to clinic every day, consuming RN time. While valuable, addressing drop-in patient needs limit RN availability for other team roles such as chronic care management. We have been working to improve our drop-in process as well as advocating for additional RN staffing to create capacity for expanded nurse team roles in the coming year.