Stories From The Nexus

This “Story from the Nexus” was recommended by Paul Grundy, MD, MPH, FACOEM, FACPM. Dr. Grundy is founding president of the Patient Centered Primary Care Collaborative and director, IBM Global Healthcare Transformation. Dr. Grundy is also a member of the national advisory  council for National Center for Interprofessional Practice and Education.

The beginning

In 2003, when Michael Magill, MD and his colleagues set out to enhance the primary care practice for University of Utah community clinics, they faced a “chicken and egg” question of which comes first – redesign the delivery system or create and train interprofessional health care teams. Clearly, both are important, but where should they start? How could they improve both patient health and satisfaction? How could education be most effectively integrated with practice?

The answers to these and other questions resulted in Care by Design, the University of Utah’s adaptation of principles of the Patient Centered Medical Home (PCMH).

According to Dr. Magill, professor and chair of family and preventive medicine, “We started with the delivery system redesign and used that as a platform for education, training people in a redesigned practice. We started our pathway a decade ago and we’ve embedded education into the redesigned practices over time.” Magill served for ten years as executive medical director of the University of Utah Hospitals and Clinics/Community Physician Group.

The model

Care by Design is the care delivery system for the 10 multidisciplinary University of Utah Community Clinics that serve approximately 120,000 patients and provide 350,000 visits annually. This nationally recognized primary care system is one of the first in the nation to combine acute, chronic and preventive care into a comprehensive system for treating patients.

Care By Design consists of three components--the care team model, appropriate access and planned care. These allow community clinic providers to plan each patient's care from before they enter the clinic through post-appointment follow-ups.

At the core of the model is collaboration between medical assistants (MAs) and physicians to optimize the patient experience. MAs assume a central role in the visit -- greeting the patient, taking the medical history, drawing blood and documenting the physician's exam. This reduces wait time and allows doctors to spend more time with their patients.

The access component balances the needs of acute patients who want same-day appointments with those who have chronic illnesses and should be regularly seen over time. Planned care uses evidence-based tools and electronic medical records to make each patient's visit more productive.

Dr. Magill comments, “I have a colleague who was seen as a patient in one of our practices. He said, ‘That was as perfect as visit as could be imagined.’ The microsystem for us is the expanded role of the medical assistant. The core team is the physician and medical assistant. The next layer includes other members of the team -- clinical pharmacists, psychologists, nurses, care managers. The experience of the patient should be a perfect visit with the right people to address their issues. We do that.”

Integrating education and practice

An early educational experience in Care by Design developed by chance. “I was presenting to a group of first-year medical students years ago. Several of them said, ‘We have to do something in the summer. Can we come and be medical assistants?’ We hired four medical students in a new job category. They loved it and did a terrific job. That became the pilot for a new experience in our redesigned curriculum.”

These days, medical students spend time in the clinics beginning in January of their first year. Every two weeks they serve as medical assistants in the medical home. They take the patients to the exam room, scribe the history in the template and stay in the room while the physician does the physical. Dr. Magill explains, “They are right there at the front line in a concrete role supported by an information system to guide them. They don’t need to know much. This clinical exposure gives them an opportunity to watch, then grow into the physician role with patients. They are part of a team from day one.”

Family practice residents work in clinic teams with medical assistants, clinical pharmacists and others. “We embed our residents in multiple setting with interprofessional teams as a matter of course. They just think that’s normal. For example, we have a geriatric clinic led by a nutrition faculty member who is also a gerontologist. The team includes a resident physician, geriatrician and care manager. Another geriatric clinic is in an assisted living facility. A key leader of the multidisciplinary team there is one of our physician assistant faculty members.”

Building and sustaining teams

A significant lesson learned by the University of Utah team was the challenge of developing a significant level of “team-ness” -- not just different professionals working in the same space, but truly working as a single, coordinated group.

Dr. Magill talks about the importance of taking time to establish a team, “You cannot possibly overestimate how much ongoing education, training and practice in team building you have to do to maintain a high functioning team. It takes much more attention than people imagine.”

“When we launched our first site, we had a fortunate disaster. We had a month delay in our ability to open the practice. Since we’d already hired everybody, we used that time to run simulations with our physicians, medical assistants and others. We wanted to see how the teams would actually function. It was terrific. We need to pay as much attention to how they function just as pilots do when they are learning to fly airplanes in simulators.”

He continues, “We have a robust quality improvement program for our two family medicine faculty/resident practices, anchored in a meeting once a month for a half day. We actually close the clinics. In one room, we have all of our physicians and faculty, residents and staff – PAs, RNs, medical assistants, care managers. They start together with common training to answer questions such as Why do we do what we do? Then they split up into various aggregations of teams, first by clinic, then by function. They address issues like ‘How are we doing in our flu shot protocol?’ Every resident is required to complete a yearlong quality improvement project leading a team. This gives them real experience leading a team.”

The story’s punch line?

Dr. Magill concludes, “I firmly believe interprofessional teams are essential to transform health care. To transform the clinicians, however, you’ve got to have the practice first, then have the learners see the practice and participate in it. We can’t send them into a broken world and expect them to do it themselves. I’m proud of our practice and building the curriculum on what is already functioning. This is a journey, we’re not done.”

For more information about University of Utah’s Care by Design, contact Dr. Michael Magill at michael.magill@hsc.utah.edu or 801-581-4074.