Primary Care on the Front Lines of Innovation
Maryjoan Ladden, PhD, RN, FAAN, is a senior program officer at the Robert Wood Johnson Foundation.
During a recent visit to my adopted home state of Massachusetts, I took a fresh look at a primary care practice I had previously known only from afar. I was part of the team visiting Cambridge Health Alliance–Union Square Family Health, which is one of 30 primary care practices recognized as exemplar models for workforce innovation by The Primary Care Team: Learning From Effective Ambulatory Practices (LEAP) project. This project, a new initiative of the Robert Wood Johnson Foundation and the MacColl Center at Group Health Research Institute, is studying these 30 practice sites to identify new strategies in workforce development and interprofessional collaboration. The overarching goal of LEAP is to better understand the innovative models that make primary care more efficient, effective, and satisfying to both patients and providers, and ultimately lead to improved patient outcomes.
This site visit took me back to my time as a nurse practitioner at Boston Medical Center, Harvard Vanguard Medical Associates, and Boston’s school-based health centers. This is where my passion for primary care began. As we prepare for millions more Americans to enter the health care system in the coming year, we must identify ways to expand access to primary care, improve the quality of care, and control costs. One important way is by exploring how to optimize the varied and expansive skill sets of all members of the primary care team. This idea has been examined in medical and popular media, but there has been little study of the workforce innovations employed by primary care practices to meet the increasing demands for health care.
The LEAP project aims to fill this gap. It examines practices that optimize the skill sets of all health care professionals and other frontline staff in ways that support consistently outstanding primary care. A key component of the LEAP project is the deployment of a team of clinicians and researchers to conduct three-day site visits to each of the 30 selected primary care practices. The team studies how each practice uses its workforce creatively to deliver easily accessible, high-quality, patient-centered health care. In October 2013, clinicians and staff from these 30 practices will meet to share best practices, and distill their innovations into training materials and technical assistance strategies that other primary care practices can use.
These “exemplar practices” represent rural, urban, and suburban primary care settings located across the United States. They include small practices, Federally Qualified Health Centers (FQHCs), nurse managed centers, residency practices in academic health centers, and large integrated delivery systems. Cambridge Health Alliance–Union Square Family Health, a family medicine practice, has nine physicians and three Physician Assistants who are supported by approximately 30 other staff members including a clinical pharmacist, behavioral health specialists and social workers, a nurse care manager, licensed practical nurse (LPN), medical assistants, and front desk staff. The clinic is divided into three teams that work as cohesive units and care for patients as a team.
Although I was aware of this particular practice from my days working in Boston, this site visit was my first opportunity to observe first-hand its unique model of care delivery. Accompanying me were three other study team members, including Clarissa Hsu, PhD, medical anthropologist; Leah Tuzzio, MPH, qualitative expert; and Sylvia Hoffmeyer, research assistant. Over our three days onsite, we explored the ins and outs of the practice’s system of care, speaking to staff members on the primary care team and to the senior leadership, and shadowing patients through their care experience. What stood out about this practice—as well as several others selected for the LEAP project—was the range of roles that each team member played. We spoke with Joe, the full time clinical pharmacist, who was an integral member of all the care teams. He provided patients with counseling and problem-solving about their medications, meeting patients where they were and finding ways to help them stay on the medications they needed to help control or prevent disease. He maintained a busy schedule of planned appointments with patients, but also was available for on-the-spot consultation. Joe also played an active role in clinical quality improvement efforts, as did most of the staff. Another great example is that the front desk staff are acknowledged by all as critical to the success of the care team. They are responsible for conducting outreach to patients, and are often consulted for their deep understanding of a patient’s personal circumstances.
Within the context of health reform, “workforce innovation” describes the use of novel and inventive approaches to staffing configurations, as well as role optimization of both professional and ancillary primary health care team members. The goals driving these innovative models of patient-centered care delivery are to improve both access to and quality of care, while keeping costs under control.
One aspect of Cambridge Health Alliance–Union Square Family Health’s unique workforce model is illustrated by the way the practice has dealt with the spatial barriers of the building that limit expansion of the patient care space and co-locating team members together.
Union Square Family Health is located in a refurbished, turn-of-the-century furniture warehouse, and the practice occupies multiple floors of the building. The structure of the building creates space limitations that prevent housing the offices of all primary care team members on the same floor. This creates significant challenges in promoting a “team” environment, where co-location is key to facilitating communication and fostering synergistic interactions among all team members. To overcome these inherited structural barriers, the practice has built a communal workstation that facilitates “team-ness” and staff cohesion.
Over the next several months, I and others from the LEAP project will share more LEAP stories from the field. These stories will highlight the innovative approaches underway across the country to expanding access to primary care, by using all members of the primary care team—clinicians and staff—creatively.