Advancing Team-Based Care: Building Your Primary Care Team to Transform Your Practice Presented 2/18/2016 as part of the CHC Primary Care Workforce Development National Cooperative Agreement

1. Welcome
Advancing Team-Based Care
WEBINAR 1: Building Your Primary Care Team to Transform Your Practice
February 18th, 2016

2. Community Health Center, Inc.
Foundational Pillars
1. Clinical Excellence- Fully Integrated teams, Fully
integrated EMR, PCMH Level 3
2. Research & Development- The Weitzman Institute is the
home of formal research, quality improvement, and R&D
3. Training the Next Generation: Post Graduate Training
Programs for nurse practitioners, postdoctoral clinical
psychologists, and students of the health professions
CHC Profile:
•Founding Year - 1972
•200+ delivery sites
•130k patients

3. The Community Health Center, Inc. and its Weitzman Institute will provide
education, information, and training to interested health centers in:
Transforming Teams
• National Webinars on the team based care model
• Invited participation in Learning Collaboratives to launch team based care at
your health center
Training the Next Generation
• Two National Webinar series on developing Nurse Practitioner and Clinical
Psychology residency programs and successfully hosting health professions
students within health centers
• Invited participation in Learning Collaboratives to implement these programs at
your health center
Email your contact information to nca@chc1.com and visit www.chc1.com/NCA.

4. Building Your Primary Care Team to Transform Your Practice
Today’s Objectives:
1. Participants will cite two pieces of evidence supporting team-based care.
2. Participants will be able to describe the roles and functions of three members of the
primary care team.

5. Get the Most Out of Your Zoom Experience
• Send in your questions using Q&A function in Zoom
• Look out for our polling questions
• Live tweet us at @CHCworkforceNCA and #primarycareteams and #HRSAnca
• Presentation and slides will be available after on our website
• CME approved activity – please complete survey
• Upcoming webinars: Register at www.chc1.com/nca

6. Building Your Primary Care Team
To Transform Your Practice:
Learning from Effective Ambulatory Practices
MacColl Center for Healthcare Innovation
Group Health Research Institute
February 18, 2016
Ed Wagner, Director Emeritus
Brian Austin, Deputy Director | Katie Coleman, Research Associate

7. Why Primary Care Teams?
Improved
clinical
outcomes
Better
patient
access and
experience
Improved
support for
complex
patients
Reduced
burnout
Become a
recognized
PCMH

8. Teams Improve Outcomes

9. Teams Can Expand Access
Type of care
Percent of
physician’s time
in traditional
practice
Estimated percent
of physician’s
work that can be
reallocated to non
clinicians
Estimated percent
of physician’s
time saved
Preventive 17 60 10
Chronic 37 25 9
Acute 46 10 5
Total 100 — 24
Thomas S. Bodenheimer and Mark D. Smith: Primary Care: Proposed Solutions To The Physician
Shortage Without Training More Physicians, Health Affairs, 32, no.11 (2013):1881-1886

10. Teamwork Improves Patient
And Staff Experience
Patients in U. Of Utah team model showed higher satisfaction
with practice and with their provider.
Day et al., Ann Fam Med 2013
“Working in a tight team structure and perceptions of a greater
team culture were associated with less clinician exhaustion.”
Willard-Grace et. al, J Am Board Fam Med 2014

11. PCT-LEAP Project Goals:
1. Select 30 high quality, innovative primary care practices that
can serve as models for improving primary care teams.
2. Visit and study each practice for 3 1/2 days
3. Summarize what we learn in a web-based Guide.
4. Disseminate the Guide to practices involved in practice
transformation, and evaluate.

12. 30 LEAP Sites

13. Team Structure:
Major Findings From Site Visits
Medical assistants, receptionists, and
lay-persons play key patient care roles .
Roles are expanded. All staff work at the
top of their license and skillsets.
All core teams supported by RN care
managers, behavioral health specialists,
pharmacists, etc.
Providers and their panels supported by
Core teams consisting of MAs, front desk,
and others.

14. Primary Care Team
CentCore
Team
Provider
-MA
Teamlet
Provider
-MA
Teamlet
Provider
-MA
Teamlet
Extended Care
Team
• Receptionist
• Team RN
• Health Coach
• Panel Manager
• RN Care Managers
• Lay Caregivers
• Pharmacists
• Behavioral Health
Specialists
• Administrative Staff

15. How Do Teams Enable Practices To Become PCMHs
Capable Of Achieving
The Quadruple Aim?
By using their teams to effectively
perform key primary care functions.

16. Informed, Activated
Patients
Comprehensive
Services
• Engaged Leadership
• Enhanced Access
Essential Practice
Functions or Competencies
• Population Management
• Planned Care
• Medication Management
• Care Management/Follow-
up
• Referral/transition
Management
• Behavioral Integration
• Self-management Support
• Clinic-Community
Linkages
• Communication
Management
• QI strategy/Meaningful Use
• Empanelment/Continuity
• High-functioning Teams
Capacity for Quality Care
The Quadruple
Aim

17. The Key Functions Or Competencies
Of Excellent Primary Care
The
Quadruple
Aim
Track, identify,
and reach out to
patients with
care gaps
Population
Management
Provide patient-
centered,
evidence-based
services
Planned Care
Self-
management
Support
Medication
management
Behavioral
Health
Integration
Provide follow-
up and care
outside the
office
Care
Management
Referral
management
Clinic-
Community
Connections
Communication
Management
Enhanced
Access
Meet patient
needs in a timely
manner

18. How do effective practices
create effective teams?
• Hire bright, energetic folks with good
interpersonal skills.
• Define key roles and tasks and distribute
them among the team members (everybody
at top of their license).
• Train staff to perform tasks.
• Use protocols and standing orders to enable
staff to operate independently.
• Establish job ladders.
• Give teams time to meet.

19. Care Team Basics
Who is on the care team?
•Those folks needed to respond to all common problems for which patients seek care.
How are they organized?
•Often, around a clinician and medical assistant/nurse dyad.
Who is responsible?
•All have authority &responsibility for elements of care. Requires trust & transparency.
What does each member do?
• The most they can in terms of patient-facing work. Training and role clarity matters.
How big are care teams?
•Smallish, 5-7 team members, communication breaks down with increasing size.
How do you know when you’re done?
•Ongoing efforts, training new staff.

20. Where to start?
•Daily Huddles
•Weekly/biweekly QI meetings
•Start with Core team 1st, then
expanded care team
Meet together
•What’s the work?
•Address staff concerns
•Understand scope of practice
•Evaluate how things are going
•Patient input
•Plan for spread
Redesign Care
Team Roles •Trust
•Training
•Titles
•Data needs
•Think hard about part-time
providers
•Standing orders
•Co-location
Facilitate
teamwork

26. www.ImprovingPrimaryCare.org
https://vimeo.com/152518627

27. Introducing CHC’s Clinical Chiefs
Veena Channamsetty, MD, Chief Medical Officer
Mary Blankson, DNP, APRN, FNP-C, Chief Nursing Officer
Timothy Kearney, Ph.D., Chief Behavioral Health Officer
Heather Crockett Miller, DDS, MPH, Chief Dental Officer

28. Open Space for Discussion

29. Reminders
Sign up for our next webinar in this series:
Enhancing the Role of the Medical Assistant
Thurs., Mar 3, 2016 2:00-3:00 PMEST
Complete our survey!
Sign up at www.chc1.com/NCA

30. Speakers
From Community Health Center, Inc.:
Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director
Kerry Bamrick, MBA, Senior Program Manager
Veena Channamsetty, MD, Chief Medical Officer
Mary Blankson, DNP, APRN, FNP-C, Chief Nursing Officer
Timothy Kearney, Ph.D., Chief Behavioral Health Officer
Heather Crockett Miller, DDS, MPH, Chief Dental Officer
From MacColl Center for Health Care Innovation, Group Health Research Institute:
Ed Wagner, MD, MPH, Director Emeritus
Brian Austin, Deputy Director
Katie Coleman, MSPH, Research Associate