Interval examination: building primary care teams in an urban academic teaching clinic

Striving toward team-based continuity: provision of same-day access and continuity in academic primary care clinics

Background

An important goal of the patient-centered medical home is increasing timely access for urgent needs, while maintaining continuity. In academic primary care clinics, meeting this goal, along with training medical residents and associated professionals, is challenging.

Methods

The aim of this study was to understand how academic primary care clinics provide continuity to patients requesting same-day access and identify factors that may affect site-level success. We conducted qualitative interviews from December 2013–October 2014 with primary care leadership involved with residency programs at 19 Veterans Health Administration academically-affiliated medical centers. Interview recordings were transcribed verbatim. To analyze the data, we created comprehensive, structured transcript summaries for each site. Site summaries were then entered into NVivo 10 software and coded by main categories to facilitate within-case and cross-case analyses. Themes and patterns across sites were identified using matrix analysis.

Results

Interviewees found it challenging to provide continuity for same-day in-person visits. Most sites took a team-based approach to ensure continuity and provide coverage for same-day access, notably using NPs, PAs, and RNs in their coverage algorithms. Further, they reported several adaptations that increased multiple types of continuity for walk-in patients, urgent care between in-person visits, and follow-up care. While this study focused on longitudinal continuity, both by individual PCPs or by a team of professionals, informational continuity and continuity of supervision, as well as, to a lesser extent, relational and management continuity, were also addressed in our interviews. Finally, most interviewees reported clinic intention to provide patient-centered, team-based care and a robust educational experience for trainees, and endeavored to structure their clinics in ways that align these two missions.

Conclusions

In contending with the tension between providing continuity and educating new clinicians, clinics have re-conceptualized continuity as team-based, creating alternative strategies to same-day visits with a usual provider, coupled with communication strategies. Understanding the effect of these strategies on different types of continuity as well as patient experience and outcomes are key next steps in the further development and dissemination of effective models for improving continuity and the transition to team-based care in the academic clinic setting.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3943-2) contains supplementary material, which is available to authorized users.

"Fellow of the Day": A Novel Trainee Role to Improve Fellows' Outpatient Continuity Clinics

RATIONALE

The implementation of team-based care models in residency programs is one method to improve patient and provider outpatient satisfaction. However, to our knowledge, this has not yet been studied in fellowship programs.

OBJECTIVES

We instituted a pilot project to test a team-based model of care in our pulmonary and critical care medicine (PCCM) fellows' clinic by creating a new outpatient role called the "Fellow of the Day," with the goal of reducing clinical disruption for the fellows, providing more educational value for medical students, and improving patient care.

METHODS

Data were collected over a 4-month time period from electronic surveys from medical students, fellows, and supervising faculty. We also used timestamp data to determine fellows' response times to patient messages.

RESULTS

After implementation of the Fellow of the Day designation, (1) fellows were more engaged in teaching the medical student (P = 0.007); (2) fellows spent less of their personal time (P = 0.04) or time away from critically ill patients to focus on patient care-related messages (P = 0.04) and paperwork (P = 0.02); and (3) medical students had improved experience with more enjoyment (P = 0.03) and active engagement in clinic (P = 0.03). The Fellow of the Day role did not affect faculty workflow. Patients received responses to their postvisit messages in a more timely manner (P = 0.003).

CONCLUSIONS

The Fellow of the Day role was successfully implemented at our institution with multiple benefits, not only to fellows but also to patients, medical students, and supervising faculty. Our education committee has recommended continuation of the role in our fellowship program.

How best to structure interdisciplinary primary care teams: the study protocol for a systematic review with narrative framework synthesis

BACKGROUND

Western publicly funded health care systems increasingly rely on interdisciplinary teams to support primary care delivery and management of chronic conditions. This knowledge synthesis focuses on what is known in the academic and grey literature about optimal structural characteristics of teams. Its goal is to assess which factors contribute to the effective functioning of interdisciplinary primary care teams and improved health system outcomes, with specific focus on (i) team structure contribution to team process, (ii) team process contribution to primary care goals, and (iii) team structure contribution to primary care goals.

METHODS AND DESIGN

The systematic search of academic literature focuses on four chronic conditions and co-morbidities. Within this scope, qualitative and quantitative studies that assess the effects of team characteristics (funding, governance, organization) on care process and patient outcomes will be searched. Electronic databases (Ovid MEDLINE, Embase, CINAHL, PAIS, Web of Science) will be searched systematically. Online web-based searches will be supported by the Grey Matters Tool. Studies will be included, if they report on interdisciplinary primary care in publicly funded Western health systems, and address the relationships between team structure, process, and/or patient outcomes. Studies will be selected in a three-stage screening process (title/abstract/full text) by two independent reviewers in each stage. Study quality will be assessed using the Mixed Methods Assessment Tool. An a priori framework will be applied to data extraction, and a narrative framework approach is used for the synthesis.

DISCUSSION

Using an integrated knowledge translation approach, an electronic decision support tool will be developed for decision makers. It will be searchable along two axes of inquiry: (i) what primary care goals are supported by specific team characteristics and (ii) how should teams be structured to support specific primary care goals? The results of this evidence review will contribute directly to the design of interdisciplinary primary care teams. The optimized design will support the goals of primary care, contributing to the improved health of populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016041884.

Improved continuity of care in a resident clinic

BACKGROUND

For residents in the out-patient clinic, continuity in patient care is an integral and vital aspect of internal medicine training, but is frequently compromised by resident in-patient schedules, the structure of the out-patient clinic and the need to comply with the increasing regulation of duty hours.

METHOD

In this study, we examined whether the creation and implementation of a new team approach, the Firms Model, would improve the continuity of patient care in the internal medicine resident out-patient clinic.

RESULTS

Before the implementation of the Firms Model, an examination of a consecutive clinic sample indicated that patients were seen by their assigned resident providers 41.9 per cent of the time (n = 1319 clinic visits). After implementation of the Firms Model, an examination of a consecutive clinic sample indicated that patients were seen by their assigned Firm resident providers 88.9 per cent of the time (n = 1341 clinic visits).

CONCLUSION

Implementation of the Firms Model resulted in a statistically significant increase in the percentage of patients seen by assigned resident providers in an internal medicine out-patient clinic, culminating in a substantial improvement in continuity of care within our resident out-patient clinic. We discuss the implications of these findings. Continuity in patient care is an integral and vital aspect of internal medicine training, but is frequently compromised.

Internal Medicine Residents' Perceptions of Team-Based Care and its Educational Value in the Continuity Clinic: A Qualitative Study

BACKGROUND

In order to teach residents how to work in interprofessional teams, educators in graduate medical education are implementing team-based care models in resident continuity clinics. However, little is known about the impact of interprofessional teams on residents' education in the ambulatory setting.

OBJECTIVE

To identify factors affecting residents' experience of team-based care within continuity clinics and the impact of these teams on residents' education.

DESIGN

This was a qualitative study of focus groups with internal medicine residents.

PARTICIPANTS

Seventy-seven internal medicine residents at the University of California San Francisco at three continuity clinic sites participated in the study.

APPROACH

Qualitative interviews were audiotaped and transcribed. The authors used a general inductive approach with sensitizing concepts in four frames (structural, human resources, political and symbolic) to develop codes and identify themes.

KEY RESULTS

Residents believed that team-based care improves continuity and quality of care. Factors in four frames affected their ability to achieve these goals. Structural factors included communication through the electronic medical record, consistent schedules and regular team meetings. Human resources factors included the presence of stable teams and clear roles. Political and symbolic factors negatively impacted team-based care, and included low staffing ratios and a culture of ultimate resident responsibility, respectively. Regardless of the presence of these factors or resident perceptions of their teams, residents did not see the practice of interprofessional team-based care as intrinsically educational.

CONCLUSIONS

Residents' experiences practicing team-based care are influenced by many principles described in the interprofessional teamwork literature, including understanding team members' roles, good communication and sufficient staffing. However, these attributes are not correlated with residents' perceptions of the educational value of team-based care. Including residents in interprofessional teams in their clinic may not be sufficient to teach residents how team-based care can enhance their overall learning and future practice.