Redesigning Primary Care: Clinics Switch to Practice Teams

Pursuing Perfection: Raising the Bar for Health Care Performance

    • October 6, 2008

The problem: HealthPartners, a nonprofit health care organization based in metropolitan Minneapolis, had taken steps to improve the care delivered by its 20 primary care clinics—including initiating an electronic medical record system and offering same-day appointment scheduling.

However, the effort hit a plateau. “We had strong quality results, but we’d reached a point where we weren’t improving significantly,” says Beth Waterman, RN, MBA, vice president, health improvement and care innovation.

John Wheeler, MD, associate medical director (since retired), put it this way: “Between the care we deliver and the care we’d like to deliver, there’s not just a gap but a chasm. The good news is we think we can do something about it.”

The proposed solution: Under the direction of Waterman and Wheeler, HealthPartners embarked on an ambitious redesign of clinic processes aimed at transforming the organization’s 638-physician medical group.

The Robert Wood Johnson Foundation (RWJF) supported this work, and other quality improvements, through Pursuing Perfection: Raising the Bar for Health Care Performance.

The plan called for reorganizing primary care around practice teams instead of individual clinicians. The concept—a modified version of the Chronic Care Model—puts the patient at the center of a collaborative effort in which nurses and clerical staff (receptionists) play expanded roles, allowing the physician to focus more fully on the patient encounter.

“The right person doing the right thing at the right time with the right patient experience”—that was the mantra for what HealthPartners christened its Planned Care Model.

The project: HealthPartners piloted the Planned Care Model at three clinics in 2004 and the next year implemented it systemwide, teaming each physician with a nurse (an LPN or CMA) and a supporting RN and receptionist.

The new approach divides the clinic visit into four phases (pre-visit, visit, post-visit and between-visits) and defines the functions of each team member at each phase.

For example, the nurse’s pre-visit duties include reviewing the patient’s electronic record to identify health maintenance, prescription and immunization needs. The nurse or receptionist then contacts the patient to encourage completion of any necessary lab work before the appointment.

In addition to consistency, the new process seeks to establish a close relationship between team members and patient—an element that can improve health outcomes, says Beth M. Averbeck, MD, associate medical director for care improvement.

She tells of a diabetic patient who had hypertension but refused to take blood pressure medicine—until the team nurse took her aside and explained the consequences.

Results: No one at HealthPartners pretends the new care process has yet reached perfection. Waterman concedes some physicians are not enthusiastic about the changes, and compliance is incomplete.

Nevertheless, initial process measures indicate the system is taking hold. At the end of the first year, clinic staff used pre-visit planning procedures for about 70 percent of patient visits. “We are delivering more consistent care to our patients, more effective care to our patients,” says Waterman.

In the last phase of the RWJF project, HealthPartners spread the new structured process to congestive heart failure patients, smoothing their transition from primary to cardiac care and from hospital to hospice. HealthPartners has since begun applying the team approach to other specialties and to its 427-bed Regions Hospital in St. Paul.

“It is completely baked in. There’s no way we could stop,” HealthPartners CEO Mary Brainerd, MBA, says of the new care process and related improvements. “It’s so clearly part of our focus. I’d say it’s the top focus.”

In recognition of the new team process, the American Medical Group Association gave HealthPartners the association’s 2006 Acclaim Award. For its overall quality effort, HealthPartners received the 2007 National Quality Healthcare Award presented by the National Quality Forum.

RWJF perspective: Pursuing Perfection was a national program to improve patient outcomes by funding providers to redesign major care processes.

RWJF Senior Program Officer Rosemary Gibson, MSc, says the results achieved by Pursing Perfection grantees send a powerful message to the field: “Health care organizations can reach new thresholds of quality and safety. It is possible to make great strides in health care. This is what happens when we develop the knowledge, skills and will to do it.”

Project Duration: September 2001–March 2006

Award: $2,250,000 (three grants)

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