Team-based care: an expanded medical assistant role - enhanced rooming and visit assistance

Supporting Primary Care Providers to Improve Adolescent Behavioral and Mental Health

Behavioral and mental health (BMH) issues are increasing in adolescents as shortages of primary care and BMH providers are also rising. The healthcare burden has fallen especially hard on primary care providers (PCPs), who are showing increasing signs of burnout and making plans to reduce their work hours or leave the profession altogether. These factors impede their ability to be the first line of defense in providing emotional support to children and families. Current solutions to BMH provider shortages include integrated models for primary and BMH health care and child psychiatric consultation services for PCPs. However, this does not diminish PCP perceptions that they are doing more screening and struggling to offer BMH support, all within shorter visit times. In this paper, we explore potential solutions to increasing time with patients and efficiency of primary care visits, and proposals to increase reimbursement for primary care providers.

A Quality Improvement Project on Team-Based Care for Depression Screening Before and During the COVID-19 Pandemic in a Specialty Clinic

BACKGROUND

Depression screening is an important first step to identifying patients who might benefit from depression treatment. Merit-based incentive payment system (MIPS) quality measures can yield financial benefits or losses for healthcare systems, including depression screening.

OBJECTIVES

This study aims to (1) develop a team-based care workflow to improve MIPS depression screening in a specialty clinic and (2) modify the workflow to include a virtual nursing and behavioral health resource after the COVID-19 pandemic hit.

METHODS

A quality improvement project, utilizing Lean Six Sigma process improvement methods, was implemented to improve team-based depression screening in a specialty clinic. A multidisciplinary team implemented plan-do-study-act cycles, created educational materials tailored to each role, developed electronic medical record (EMR) tools to alert and assist team members in screening, and ensured the EMR aligned with the MIPS criteria. The percentage of eligible visits where depression screening was performed was analyzed across four study periods: pre-intervention, post-intervention, COVID-19, and recovery. Recovery strategies included developing telehealth workflows, establishing centralized registered nurse triage groups, and using phone-based triage and support resources at virtual visits.

RESULTS

Utilizing team-based strategy and available or newly developed tools, the percentage of eligible visits with completed depression screening was as follows: 1.4% pre-intervention, 58.2% post-intervention, 3.5% COVID-19, and 64.0% recovery. With the COVID-19 pandemic outbreak, initially, improved screening performance declined sharply. Recovery was achieved through the revision of workflows, team members, and support tools.

CONCLUSIONS

A team-based care approach can successfully improve and maintain depression screening in a specialty clinic and was versatile enough to be readapted to virtual visits during the COVID-19 pandemic. In addition to impacting MIPS quality incentives, the depression screening workflows described in this article can be adapted to other uses, including virtual and in-person visits and in other specialty or chronic disease settings.

Overcoming challenges of prescribing long-term opioid therapy in residency clinics

OBJECTIVES

To describe the impact of a standardized opioid prescribing intervention when implemented in three family medicine (FM) residency training - clinics-environments that face operational challenges including regular resident turnover.

DESIGN

We performed a retrospective cohort study to compare patterns of long-term opioid prescribing between residency and nonresidency clinics.

SETTING

This study took place within a large, academic, health system.

PATIENTS AND PARTICIPANTS

Three FM residency clinics were compared with three nonresidency FM clinics.

INTERVENTIONS

A standardized opioid prescribing process was developed and implemented within the FM residency clinics. Nonresidency clinics used an independent process and were not exposed to the intervention.

MAIN OUTCOME MEASURES

Descriptive comparisons were performed for treatment and control clinics' opioid prescribing from 2015 to 2018. The primary outcome was a patient's annual opioid exposure supplied from these select clinics. We also examine coprescribing with high-risk medications that potentiate the overdose risk of opioid prescriptions. Difference-in-difference modeling was used to control for clinic-level variation in practice.

RESULTS

Statistically significant decreases were observed in both residency and nonresidency clinics for the mean number of opioid prescriptions and the mean daily morphine milligram equivalent. These decreases were comparable between the residency and nonresidency clinics.

CONCLUSIONS

Residency clinics face unique challenges and require innovative solutions to keep up with best practices in opioid prescribing. Our residency clinics' implementation of a standardized intervention, including electronic health record integration, standardized processes, and metric management, suggests steps that may be valuable in achieving outcomes comparable to nonresidency clinics in large health systems.

[Effectiveness of the clinical assistant in the control of hypertensive and diabetic patients in primary care]

OBJECTIVE

To evaluate the effectiveness of the incorporation of the clinical assistant in improving the control of type 2 diabetes mellitus and hypertension in a primary care center.

DESIGN

Quasi-experimental study (pre-post), with a control group, with a 1-year follow-up.

SETTING

Primary care center.

PARTICIPANTS

Patients between the ages of 18 and 85 with a diagnosis of diabetes type 2 and/or hypertension were selected.

INTERVENTION

Incorporation of the figure of the clinical assistant, previously trained. The latter contacted the patient to explain their role and obtain informed consent, assessed compliance with the protocols, and when they were incomplete and/or detected warning signs, referred the patient directly to medicine and/or nursing.

RESULTS

Three thousand and sixty-four patients participated, 30.74% assigned to the intervention group. Fifty percent were women. The mean age was 68.5 years (SD 11.07). 93.59% of diabetic patients in the intervention group had at least one determination of glycosylated hemoglobin compared to 86.83% in the control group (p=0.003). Fundus and diabetic foot screening was significantly higher in the intervention group (94.31% and 85.41% vs. 83.49% and 72.38%). 88.43% of the patients in the intervention group had registered blood pressure figures compared to 62.06% of the patients in the control group (p<0.05). There were not statistically significant differences in the control of blood pressure between the patients with recorded measures (p=0.478).

CONCLUSIONS

Clinical assistants can facilitate the implementation and compliance with chronic diseases protocols, and in the long run improve the degree of control of these patients and the quality of care.

Effectiveness of Doctor Clerks Supporting Physicians' Work in Japan: A Systematic Review

The burgeoning administrative workload on physicians in Japan's healthcare system has necessitated innovative approaches to optimize clinical care. Integrating doctor clerks, tasked with administrative and clerical duties, has emerged as a potential solution to alleviate this burden. This systematic review aims to evaluate the effectiveness of doctor clerks in improving physicians' working conditions and patient care quality. A comprehensive literature search was conducted using Ichushi Web and Google Scholar from January 2000 to September 2023. Data were extracted on publication year, study setting, department focus, work scope, and outcomes of doctor clerk implementation. The search identified 3570 studies, with 17 meeting the inclusion criteria. Most studies were performed in general hospitals with 76.5% (13/17). The studies regarding university hospitals were 17.6% (3/17). Only one study was performed in a community hospital with 5.9% (1/17). More than half of doctor clerks worked not explicitly allocated to one department and did their work not specific to one department with 52.9% (9/17). Three studies report that doctor clerks collaborate with orthopedic surgeons. Two studies report that doctor clerks collaborate with emergency medicine physicians. Each study reports that doctor clerks collaborate with respiratory or general medicine. The most frequent is document support, with 94.1% (16/17). The second most frequent working content is consultation support, with 47.1% (8/17). The third most frequently working content is ordering support, with 23.5% (4/17). Call response, secretary work, education support, research support, conference support, and other professional support are included, each with 5.9% (1/17). Regarding clinical outcomes, five studies assessed a reduction in physician paperwork time (29.4%). Four studies assessed the frequency of the contents of doctor clerks' work (23.5%). Four studies assessed the positive perception of physicians (23.5%). Four studies assessed the amount of the reduction in physicians' overtime work (23.5%). Three studies assess the amount of the reduction in hospital costs (17.6%). One study assessed part-time physicians' fatigue reduction (5.9%). Each study assessed the quality of patient care, such as doctor's clerk education for standardization, increase in the number of patients accepted, reduction in medical incidents, decrease in patient waiting time, and primary to tertiary prevention. Introducing doctor clerks in Japan's healthcare system shows promise in enhancing physicians' working conditions and potentially improving patient care. However, conclusive evidence on the impact on patient care quality necessitates further investigation, serving as a foundation for future policy and healthcare system optimization.

From the Nexus vision to the NexusIPE™ learning model

The Nexus vision of simultaneously transforming health professions education and healthcare delivery to achieve Triple (now Quadruple) Aim outcomes was first articulated in the 2012 proposal and funding of the National Center for Interprofessional Practice and Education (National Center). Over the past decade, the National Center has worked with over 70 sites implementing large scale and practice-based interprofessional practice and education (IPE) programs. Because what is needed to implement the Nexus to achieve Quadruple Aim outcomes was not well understood in 2012, the National Center took a social innovations and developmental evaluation approach. This iterative method led to the development of the National Center NexusIPE™ Learning Model that adapts the 3-P high-level stages (Presage, Process, and Product), proposed as a framework for IPE by Barr and colleagues. National Center collaborators' lessons learned about the Nexus vision are highlighted in this issue and provide real-world examples of elements of the NexusIPETM Learning Model. Reflecting on ten years of experience, the National Center leaders recognize the need for Nexus transformation and the relevance of the NexusIPETM Learning Model today as education and health systems grapple with mounting workforce challenges. The model provides opportunities to address growing workforce shortages, provide equitable care that leads to health, and support the well-being of practice teams in the face of challenges such as the COVID-19 pandemic.

Doctor Clerk Implementation in Rural Community Hospitals for Effective Task Shifting of Doctors: A Grounded Theory Approach

With the diversification of medical care and work reform, doctor clerks play a major role today and are recruited to mitigate the burden of doctors worldwide. Their recruitment can improve the working conditions of physicians, facilitate task shifting in rural community hospitals, improve patient care, and help address the lack of healthcare resources. This study used a qualitative method to investigate difficulties in the implementation of doctor clerks and ascertain the features of effective implementation by collecting ethnographic data through field notes and semi-structured interviews with workers. We observed and interviewed 4 doctor clerks, 10 physicians, 14 nurses, 2 pharmacists, 1 nutritionist, and 2 therapists for our study. We clarified the doctor clerk process in rural hospitals through four themes: initial challenge, balance between education and expansion, vision for work progression, and drive for quality of care. We further clarified effectiveness, difficulties, and enhancing factors in implementation. Doctor clerk recruitment and bridging of discrepancies among medical professionals can mitigate professional workloads and improve staff motivation, leading to better interprofessional collaboration and patient care.

A Lung Cancer Screening Education Program Impacts both Referral Rates and Provider and Medical Assistant Knowledge at Two Federally Qualified Health Centers

BACKGROUND

Federally Qualified Health Centers (FQHCs) serve minority and low-socioeconomic populations and provide care to high-risk smokers. These centers frequently experience barriers, including low provider and medical assistant (MA) knowledge around lung cancer screening (LCS). Subsequent low LCS referral rates by providers at FQHCs limit utilization of LCS in eligible, high-risk, underserved patients.

METHODS

Providers and MAs from two FQHCs participated in a LCS educational session. A pre-educational survey was administered at the start of the session and a post-educational survey at the end. The intervention included a presentation with education around non-small cell lung cancer, LCS, tobacco cessation, and shared-decision making. Both surveys were used to evaluate changes in provider and MA ability to determine eligible patients for LCS. The Pearson's Chi-squared test with Yates' continuity correction was used to measure the impact.

RESULTS

A total of 29 providers and 28 MAs enrolled in the study from two FQHCs. There was an improvement, P < .009 and P < .015 respectively, in provider and MA confidence in identifying patients for LCS. Additionally, one year prior to the program, 9 low-dose computed tomography (LDCTs) were ordered at one of the FQHCs and 0 at the other. After the program, over 100 LDCTs were ordered at each FQHC.

CONCLUSIONS

A targeted LCS educational program improves provider and MAs' ability to identify eligible LCS patients and is associated with an increase in the number of patients referred to LDCT at FQHCs.

Investigating the Use of Telemedicine for Digitally Mediated Delegation in Team-Based Primary Care: Mixed Methods Study

Background

Owing to the shortage of medical professionals, as well as demographic and structural challenges, new care models have emerged to find innovative solutions to counter medical undersupply. Team-based primary care using medical delegation appears to be a promising approach to address these challenges; however, it demands efficient communication structures and mechanisms to reinsure patients and caregivers receive a delegated, treatment-related task. Digital health care technologies hold the potential to render these novel processes effective and demand driven.

Objective

The goal of this study is to recreate the daily work routines of general practitioners (GPs) and medical assistants (MAs) to explore promising approaches for the digital moderation of delegation processes and to deepen the understanding of subjective and perceptual factors that influence their technology assessment and use.

Methods

We conducted a combination of 19 individual and group interviews with 12 GPs and 14 MAs, seeking to identify relevant technologies for delegation purposes as well as stakeholders’ perceptions of their effectiveness. Furthermore, a web-based survey was conducted asking the interviewees to order identified technologies based on their assessed applicability in multi-actor patient care. Interview data were analyzed using a three-fold inductive coding procedure. Multidimensional scaling was applied to analyze and visualize the survey data, leading to a triangulation of the results.

Results

Our results suggest that digital mediation of delegation underlies complex, reciprocal processes and biases that need to be identified and analyzed to improve the development and distribution of innovative technologies and to improve our understanding of technology use in team-based primary care. Nevertheless, medical delegation enhanced by digital technologies, such as video consultations, portable electrocardiograms, or telemedical stethoscopes, can counteract current challenges in primary care because of its unique ability to ensure both personal, patient-centered care for patients and create efficient and needs-based treatment processes.

Conclusions

Technology-mediated delegation appears to be a promising approach to implement innovative, case-sensitive, and cost-effective ways to treat patients within the paradigm of primary care. The relevance of such innovative approaches increases with the tremendous need for differentiated and effective care, such as during the ongoing COVID-19 pandemic. For the successful and sustainable adoption of innovative technologies, MAs represent essential team members. In their role as mediators between GPs and patients, MAs are potentially able to counteract patients’ resistance toward using innovative technology and compensate for patients’ limited access to technology and care facilities.

Transforming Interprofessional Roles During Virtual Health Care: The Evolving Role of the Medical Assistant, in Relationship to National Health Profession Competency Standards

Introduction:

Medical assistants (MAs) were once limited to obtaining vital signs and office work. Now, MAs are foundational to team-based care, interacting with patients, systems, and teams in many ways. The transition to Virtual Health during the COVID-19 pandemic resulted in a further rapid and unique shift of MA roles and responsibilities. We sought to understand the impact of this shift and to place their new roles in the context of national professional competency standards.

Methods:

In this qualitative, grounded theory study we conducted semi-structured interviews with 24 MAs at 10 primary care sites at a major academic medical center on their experiences during the shift from in-person to virtual care. MAs were selected by convenience sample. Coding was done in Dedoose version 8.335. Consensus-based inductive and deductive approaches were used for interview analysis. Identified MA roles were compared to national MA, Institute of Medicine, physician, and nursing professional competency domains.

Results:

Three main themes emerged: Role Apprehension, Role Expansion, and Adaptability/Professionalism. Nine key roles emerged in the context of virtual visits: direct patient care (pre-visit and physical care), panel management, health systems ambassador, care coordination, patient flow coordination, scribing, quality improvement, and technology support. While some prior MA roles were limited by the virtual care shift, the majority translated directly or expanded in virtual care. Identified roles aligned better with Institute of Medicine, physician, and nursing professional competencies, than current national MA curricula.

Conclusions:

The transition to Virtual Health decreased MA’s direct clinical work and expanded other roles within interprofessional care, notably quality improvement and technology support. Comparison of the current MA roles with national training program competencies identified new leadership and teamwork competencies which could be expanded during MA training to better support MA roles on inter-professional teams.

Team-based approach to improving medication reconciliation rates in family medicine residency clinics

OBJECTIVE

The objective of this quality improvement project was to design and implement a systematic team-based care approach to medication reconciliation, with a goal of physician-documented medication reconciliation at 70% of all patient office visits.

SETTING

Ambulatory clinics located in urban, underserved communities in Minneapolis and St. Paul, MN.

PRACTICE DESCRIPTION

Four family medicine residency clinics, with pharmacists integrated at each site. All clinics use the Epic electronic medical record (Epic Systems Corporation).

PRACTICE INNOVATION

A team-based care approach to medication reconciliation was designed and implemented involving medical assistants (MAs), physicians, and pharmacists. The MAs did an initial review with patients, the physicians addressed discrepancies, and difficult situations were escalated to the pharmacist for a detailed assessment.

EVALUATION

The percentage of visits with physician-documented medication reconciliation was measured preintervention and then for 18 months postintervention in 6-month intervals involving more than 118,000 patient visits. Satisfaction surveys of team members were done pre- and postintervention.

RESULTS

The percentage of visits with physician-documented medication reconciliation improved significantly from 6.5% preintervention to 58.7% (P < 0.001) postintervention, and was sustained and further improved to 70.3% (P < 0.001) 1 year later. The team members had a statistically significant improvement in their ability to articulate the medication reconciliation process. Satisfaction improved significantly for physicians, but MAs did not experience a statistically significant change.

CONCLUSION

A team-based care approach to medication reconciliation was successfully implemented and sustained at 4 family medicine clinics. There was significant improvement in physician-documented medication reconciliation. Future studies need to address whether this process improves medication-list discrepancies, completeness, and accuracy.