Building a health care team is a core principle in creating patient-centered care, which is becoming more important with the increased focus on quality and value.
Read some examples below from Pennsylvania physicians about how they are utilizing health care teams in their practice to improve patient care.
Through a variety of programs, Renaissance Medical Management Company has achieved clinical outcomes rivaling the top national benchmarks in congestive heart failure, coronary artery disease, and diabetes.
One of the early innovations was the development of a new role within each location—the quality improvement (QI) physician. This physician was educated in quality management and processes to serve, stimulate, and provide oversight to quality improvement methods within their practice.
They are responsible for physician understanding and adoption of clinical best practice models, team processes, and a unified understanding of current performance and goals. QI physicians lead discussions individually and collectively with physicians in their practices to address the needs of specific patients and improve overall quality outcomes.
Kenneth Goldblum, MD
Renaissance Medical Management Company
Wayne
An internal review of the effectiveness of teaching and management rounds noted that faculty had varying rounding habits and inconsistent communication with other disciplines, which may lead to missed information, decreased patient and family satisfaction, and increased length of stay (LOS). Objectives of the project: Gaps in communication between disciplines were identified as the principal reason for increased LOS and decreased patient satisfaction, along with increased frustration of health care providers. In response, the Internal Medicine Residency Program, in collaboration with other departments, developed multidisciplinary rounds (MDR) on medical/surgical floors. With this team approach, faculty, residents, nurses, case managers, social workers, and others can bring their expertise to the bedside in a structured and time efficient way.
Results to date:
- LOS decreased by 0.34 days
- Enhanced patient satisfaction
- Satisfaction of nursing staff
- Significance
Saba Hasan, MD
Capital Health Regional Medical Center
Trenton, NJ
We are training our medical assistants to be health coaches and case managers. Most patient-centered medical homes use registered nurses or diabetic educators to teach patients about their chronic diseases. We don’t have the funds to hire specialized nurses or educators.
Over the past year, we held educational sessions for our medical assistants (MAs), teaching them disease processes and basic pharmacology. Currently, we are planning a session to teach motivational interviewing to our MAs. We have found our MAs to be eager learners and willing to take on new responsibilities. Since each doctor has a consistent MA, they know our patients well and have been very effective in promoting behavioral change. We also are working with our MAs to help bridge gaps in transitions of care.
When we receive an emergency room report or hospital discharge summary, the MA makes sure the patient is seen in our office within a week. They also track patients who go to rehab or short-term nursing facilities and make sure they come to our office as soon as they return home.
Jean Stretton, MD
Gateway Internal Medicine of West Chester
West Chester
We have a 15 minute structured huddle to start each session in the office. This better coordinates care for our team, identifies opportunities for preventive care, identifies opportunities for chronic care when appropriate, and facilitates feedback in what can commonly be a somewhat intense environment.
Matthew Howie, MD
York Hospital Community Health Center