Barriers and facilitators to team-based care in the context of primary care transformation

Developing Relational Coordination: A Qualitative Study of Outpatient Mental Health Teams

Previous studies have shown Relational Coordination improves team functioning in healthcare settings. The aim of this study was to examine the relational factors needed to support team functioning in outpatient mental health care teams with low staffing ratios. We interviewed interdisciplinary mental health teams that had achieved high team functioning despite low staffing ratios in U.S. Department of Veterans Affairs medical centers. We conducted qualitative interviews with 21 interdisciplinary team members across three teams within two medical centers. We used directed content analysis to code the transcripts with a priori codes based on the Relational Coordination dimensions, while also being attentive to emergent themes. We found that all seven dimensions of Relational Coordination were relevant to improved team functioning: frequent communication, timely communication, accurate communication, problem-solving communication, shared goals, shared knowledge, and mutual respect. Participants also described these dimensions as reciprocal processes that influenced each other. In conclusion, relational Coordination dimensions can play pivotal roles in improving team functioning both individually and in combination. Communication dimensions were a catalyst for developing relationship dimensions; once relationships were developed, there was a mutually reinforcing cycle between communication and relationship dimensions. Our results suggest that establishing high-functioning mental health care teams, even in low-staffed settings, requires encouraging frequent communication within teams. Moreover, attention should be given to ensuring appropriate representation of disciplines among leadership and defining roles of team members when teams are formed.

Prevalence and predictors of team-based care activities between primary care providers and embedded behavioral health providers: a national survey

Primary care (PC) settings increasingly use team-based care activities with embedded behavioral health providers (BHPs) to enhance patient care via group medical visits, conjoint appointments, team huddles, and warm handoffs. Aim 1 was to describe the variation of team-based care activities within integrated PC clinics. Aim 2 was to explore whether factors associated with the BHP (e.g., gender, training, and experience) and the PC setting (e.g., perceived teamwork) predict engagement in team-based activities. A national sample of eligible BHPs (n = 345; 14.2% response rate) completed an anonymous survey assessing the presence/intensity of team-based care activities. 90% of BHPs reported regularly engaging in team-based care activities with PC teams. Most engagement occurred when providing feedback to PC providers (90.4% at least daily) and during warm handoffs (90.4% at least once daily). Engagement in team-based care was predicted by the level of teamwork occurring within the PC clinic (βs = .41-.47; ps < .001) and BHP characteristics, such as the number of years spent in PC (βs = .24-.26, ps < .001). Although these data are promising, with many BHPs reportedly engaging in team-based activities with PC teams, there is significant variation. Researchers should continue to explore whether the engagement in these team-based care activities enhances patient care.

Advancing research on teams and team effectiveness in implementation science: An application of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework

Background

Effective teams are essential to high-quality healthcare. However, teams, team-level constructs, and team effectiveness strategies are poorly delineated in implementation science theories, models, and frameworks (TMFs), hindering our understanding of how teams may influence implementation. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework is a flexible and accommodating framework that can facilitate the application of team effectiveness approaches in implementation science.

Main Text

We define teams and provide an overview of key constructs in team effectiveness research. We describe ways to conceptualize different types of teams and team constructs relevant to implementation within the EPIS framework. Three case examples illustrate the application of EPIS to implementation studies involving teams. Within each study, we describe the structure of the team and how team constructs influenced implementation processes and outcomes.

Conclusions

Integrating teams and team constructs into the EPIS framework demonstrates how TMFs can be applied to advance our understanding of teams and implementation. Implementation strategies that target team effectiveness may improve implementation outcomes in team-based settings. Incorporation of teams into implementation TMFs is necessary to facilitate application of team effectiveness research in implementation science.

The Impact of COVID-19 on Primary Care Teamwork: a Qualitative Study in Two States

BACKGROUND

The emergence of coronavirus disease 2019 (COVID-19) disrupted how primary care physicians (PCPs) and their staff delivered team-based care.

OBJECTIVE

To explore PCPs' perspectives about the impact of stay-at-home orders and the increased use of telemedicine on interactions and working relationships with their practice staff during the first 9 months of the pandemic.

DESIGN

Qualitative research.

PARTICIPANTS

Participants included PCPs from family and community medicine, general internal medicine, and pediatrics.

APPROACH

One-on-one, semi-structured video interviews with 42 PCPs were conducted between July and December 2020. Physicians were recruited from 30 primary care practices in Massachusetts and Ohio using a combination of purposeful, convenience, and snowball sampling. Interview questions focused on work changes and work relationships with other staff members during the pandemic as well as their experiences delivering telemedicine. All interviews were audio-recorded, transcribed verbatim, and coded using deductive and inductive approaches.

KEY RESULTS

Across respondents and states, the context of the pandemic was reported to have four major impacts on primary care teamwork: (1) staff members' roles were repurposed to support telemedicine; (2) PCPs felt disconnected from staff; (3) PCPs had difficulty communicating with staff; and (4) many PCPs were demoralized during the pandemic.

CONCLUSIONS

The lack of in-person contact, and less synchronous communication, negatively impacted PCP-staff teamwork and morale during the pandemic. These challenges further highlight the importance for practice leaders to recognize and attend to clinicians' relational and work-related needs as the pandemic continues.

Persuasive Design Techniques and App Design Recommendations to Improve Health Workforce Capability in Rural Health Professionals: What Do Users Want and How Does an App Help?

BACKGROUND

Health professionals' perceptions of persuasive design techniques for use in technological solutions to improve health workforce capability have not been previously explored.

OBJECTIVE

This study aims to explore rural health professionals' perceptions of health workforce capability and persuasive design techniques; and translate these into recommendations for designing a health workforce capability app to increase their impact and usefulness.

METHODS

Qualitative interviews with 13 rural health professionals were conducted. Subsequently, 32 persuasive techniques were used as a framework to deductively analyze the data. Persuasive design technique domains were Primary Task Support, Dialog Support, System Credibility Support, Social Support, and Cialdini's Principles of Persuasion.

RESULTS

Persuasive design techniques can be applied across the factors that influence health workforce capability including health and personal qualities; competencies and skills; values, attitudes, and motivation; and factors that operate outside of work and at the team, organizational, and labor market levels. The majority of the 32 persuasive design techniques were reflected in the data from the interviews and led to recommendations as to how these could be translated into practice, with the exception of scarcity. Many suggestions and persuasive design techniques link back to the need for tailored and localized solutions such as the need for country-specific-based evidence, the wish for localized communities of practice, learning from other rural health professionals, and referral pathways to other clinicians. Participants identified how persuasive design techniques can optimize the user experience to help meet rural health professionals needs for more efficient systems to improve patient access to care, quality care, and to enable working in interprofessional team-based care. Social inclusion plays a vital role for health professionals, indicating the importance of the Social Support domain of persuasive techniques. Overall, health professionals were open to self-monitoring of their work performance and some professionals used wearables to monitor their health.

CONCLUSIONS

Rural health professionals' perceptions of health workforce capability informed which persuasive design techniques can be used to optimize the user experience of an app. These were translated into recommendations for designing a health workforce capability app to increase likelihood of adoption. This study has also contributed to the further validation of the Persuasive Systems Design model through empirically aligning elements of the model to increase persuasive system content and functionality with real-world applied data, in this case the health workforce capability of rural health professionals. Our findings confirm that these techniques can be used to develop a future prototype of an app that may assist health professionals in improving or maintaining their health workforce capability which in turn may increase recruitment and retention in rural areas. Health professionals need to be central during the design phase. Interventions are needed to provide a supportive environment to rural and remote health professionals to increase their rural health workforce capability.

Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial

BACKGROUND

Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms.

METHODS

We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life.

DISCUSSION

This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

'Trying to fly the plane while we were building it'. Applying a learning health systems approach to evaluate early-stage barriers and facilitators to implementing primary care transformation: a qualitative study

OBJECTIVE

A learning health system (LHS) uses data to generate evidence and answer questions required to continually improve system performance and patient care. Given the complexities of practice transformation, an area where LHS is particularly important is the study of primary care transformation (PCT) as PCT generates several practice-level questions that require study where the findings can be readily implemented. In May 2019, a large integrated health delivery system in Minnesota began implementation of a population management PCT in two of its 40 primary care clinics. In this model of care, patients are grouped into one of five service bundles based on their complexity of care; patient appointment lengths and services provided are then tailored to each service bundle. The objective of this study was to examine the use of a LHS in PCT by utilising the Consolidated Framework for Implementation Research (CFIR) to categorise implementation lessons from the initial two PCT clinics to inform further implementation of the PCT within the health system.

DESIGN

This was a formative evaluation in which semistructured qualitative interviews were carried out. Observational field notes were also taken. Inductive coding of the data was performed and resultant codes were mapped to the CFIR.

SETTING

Two suburban primary care clinics in the Twin Cities, Minnesota.

PARTICIPANTS

Twenty-two care team members from the first two clinics to adopt the PCT.

RESULTS

Seventeen codes emerged to describe care team members' perceived implementation influences. Codes occurred in each of the five CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals and process), with most codes occurring in the 'inner setting' domain.

CONCLUSIONS

Using an LHS approach to determine early-stage implementation influences is key to guiding further PCT implementation, understanding modifications that need to be made and additional research that needs to occur.

Integrating Personalized Care Planning into Primary Care: a Multiple-Case Study of Early Adopting Patient-Centered Medical Homes

BACKGROUND

Personalized care planning is a patient-centered, whole-person approach to treatment planning. Personalized care plans improve patient outcomes and are now mandated for chronic care management reimbursement. Yet guidance on how to best implement personalized care planning in practice is limited.

OBJECTIVE

We examined the adoption of personalized care planning in patient-centered medical home (PCMH) clinics to identify processes and organizational characteristics that facilitated or hindered use in routine practice.

DESIGN

Qualitative multiple-case study design. We conducted site visits at PCMH clinics in four US Veterans Health Administration (VHA) medical centers. Data included 10 general clinic observations, 34 direct observations of patient-provider clinical encounters, 60 key informant interviews, and a document review. Data were analyzed via qualitative content analysis using a priori and emergent coding.

PARTICIPANTS

Employees and patients participating in clinical encounters in PCMH clinics at four VHA medical centers.

KEY RESULTS

Each clinic used a distinct approach to personalized care planning: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. Each varied in workflow, healthcare team utilization, and degree of integration into clinical care. Across sites, critical components for implementation included expanding planning beyond initial assessment of patient priorities; framing the initiative for patients; using a team-based approach to care plan development and updates; using communication mechanisms beyond the electronic health record; and engaging stakeholders in implementation planning.

CONCLUSIONS

Personalized care planning is a novel patient-centered practice, but complicated to implement. We found variation in effective implementation and identified critical components to structuring this practice in a manner that engages patients in treatment aligned with personal priorities. Primary care practices seeking to implement personalized care planning must go beyond simply asking patients a series of questions to establish a plan. They must also engage team members in plan development, communication, and dissemination.

Patient-Centered Medical Home With Colocation: Observations and Insights From an Academic Family Medicine Clinic

There is a movement in the United States to transform family medicine practices from single physician–based patient care to team-based care. These teams are usually composed of multiple disciplines, including social workers, pharmacists, registered nurses, physician assistants, nurse practitioners, and physicians. The teams support patients and their families, provide holistic care to patients of all ages, and allow their members to work to the highest level of their training in an integrated fashion. Grouping care team members together within visual and auditory distance of each other is likely to enhance communication and teamwork, resulting in more efficient care for patients. This grouping is termed colocation. The authors describe how the use of colocation can lead to clearer, faster communication between care team members. This practice style has the potential to be expanded into various clinical settings in any given health system and to almost all clinical specialties and practices.

Function of the Medical Team Quarterback: Patient, Family, and Physician Perspectives on Team Care Coordination in Patient- and Family-Centered Primary Care

CONTEXT

Patient- and family-centered care (PFCC) literature is growing, but few reports present patient, caregiver, and practitioner perspectives about care coordination in a team-based model.

OBJECTIVE

To understand the patient's, caregiver's, and physician's ideal forms of PFCC, we investigated the function of the medical team quarterback, who coordinates and advocates for appropriate care, and probed to understand how the quarterback works with a team to contribute to ideal PFCC.

DESIGN AND MAIN OUTCOME MEASURES

Nine focus groups with 92 participants were held in 3 major cities. Patients (n = 35) and family members (n = 36) were recruited through market research groups. Physicians (n = 21) were recruited by the American College of Physicians. Focus group transcripts were analyzed and coded using inductive analysis.

RESULTS

The quarterback emerged as an important function for addressing care gaps and improving the care experience. We identified 6 themes articulated by participants that defined the role of a medical team quarterback: Overseeing care; coordinating diagnoses, tests, and treatments; advocating for patients; identifying and respecting patient values; proactively communicating; and solving problems. Patients and family members in our sample were open to different members of the care team acting as quarterback in coordination with the physician.

CONCLUSION

Medical team quarterbacks were perceived as enhancing team-based care by facilitating the coordination/communication that is critical to PFCC. Patients and family members acknowledged that PFCC can be delivered by different members of the medical team if the care felt organized and coordinated with the primary care physician.

Creating and Sustaining Care Teams in Primary Care: Perspectives From Innovative Patient-Centered Medical Homes

OBJECTIVE

To learn from the experiences of innovative primary care practices that have successfully developed care teams.

RESEARCH DESIGN

A 2½-day working conference was convened with representatives from 10 innovative primary care practices, content experts, and researchers to discuss experiences of developing care teams. Qualitative data included observation notes, transcripts of conference sessions and interviews, and narrative summaries of innovations. Case summaries of practices and an analysis matrix were created to identify common themes.

PARTICIPANTS

Ten practices known nationally for innovations in team-based care participated in the conference represented by 1 to 2 practice members.

RESULTS

Two domains emerged related to creating effective teams and funding them. Participants emphasized the importance of making practice values explicit and involving everyone in the change process, standardizing routine processes, and mitigating resistance. They also highlighted that team-based care adds comprehensiveness, not necessarily productivity. They, thus, highlighted the need for a long-term financial vision, including resourcefulness and alternate funding.

CONCLUSIONS

Team-based care is possible and valuable in primary care. It is difficult to develop and sustain, however, and requires dedicated time and resources. The challenges these highly motivated practices described raise the question of feasibility for more average practices in the current funding environment.

Communication Among Team Members Within the Patient-centered Medical Home and Patient Satisfaction With Providers: The Mediating Role of Patient-Provider Communication

BACKGROUND

The Patient-centered Medical Home (PCMH) uses team-based care to improve patient outcomes, including satisfaction. The quality of patients' communication with their primary care providers (PCPs) is a key determinant of patient satisfaction. A shift to team-based care could disrupt the therapeutic relationship between patients and their PCPs and reduce patient satisfaction if communication and coordination among primary care team members is poor. Little is known about the relationship between intrateam communication within a PCMH and patient satisfaction with PCPs, and whether patient-provider communication might mediate this relationship.

OBJECTIVES

To examine the relationship between intrateam communication in a PCMH and patients' satisfaction with assigned PCPs, and whether patient-provider communication mediates this relationship.

RESEARCH DESIGN

Cross-sectional surveys of Veterans Health Administration PCPs (2011-2012, n=149) matched with their assigned patients' surveys (n=3329). Mediation analyses using a nested data structure, controlling for patient and provider characteristics.

MEASURES

Patient satisfaction with PCPs, patient-reported patient-provider communication, and PCP-reported intrateam communication within the PCMH.

RESULTS

Intrateam communication and patient-provider communication were independently associated with patients' satisfaction with their PCPs. Patient-provider communication mediated 56% of the association between intrateam communication and patient satisfaction. Better intrateam communication combined with better patient-provider communication predicted high satisfaction (81%), compared with poor intrateam communication and poor patient-provider communication (22%).

CONCLUSIONS

PCMH environments with better communication among team members are likely to experience better patient-provider communication and high patient satisfaction. PCMH practices with low ratings of patient satisfaction may need to look beyond individual PCPs to communication within and across teams.

Guideline Implementation in Standardized Office Workflows and Exam Types

BACKGROUND

Clinical practice guidelines (CPGs) in medicine are recommendations supported by systematic review of evidence to facilitate optimal patient outcomes. Primary care practices are expected to implement more than 200 CPGs, overwhelming many practices. This qualitative study elucidated the perspectives and priorities of family medicine physicians and office managers in grouping CPGs to facilitate implementation.

METHODS

A qualitative study was performed using individual, semistructured interviews. During the interviews the participants completed an open card-sort exercise grouping 20 CPGs. Purposive sampling was used to identify family medicine physicians and office managers practicing in medically underserved zip codes listed in the local medical society directory. Seven physicians and 6 office managers were interviewed. The interviews were transcribed and analyzed using thematic analysis and compared with the card-sort results.

RESULTS

Thematic content analysis identified priorities and perspectives of office managers and physicians when grouping multiple CPGs for implementation: delegation, personalization, triggers, and change management. The card sort exercise revealed grouping by standardized preventive care visit, standardized rooming and discharge processes, and chronic illness. Chronic illness-based groupings and personalization of guidelines were recognized as presenting barriers to delegation of CPGs to the care team. Development of standardized preventive exams, standard rooming and discharge processes and chronic disease management were identified as promoting CPG adherence through team-based care. Standardized workflows provided opportunities for task delegation through predicable roles. Medicalization of CPG implementation relied heavily on the physician alone to remember to adhere to CPGs and inhibited task sharing by not giving office staff clear disease-based protocols to follow.

CONCLUSIONS

This study identified priorities and perspectives of office managers and physicians when grouping multiple CPGs for concomitant implementation: delegation, personalization, triggers, and change management. Successful implementation was perceived to be associated with standardized preventive exams, standard rooming and discharge processes, and chronic disease management.

Baseline measures of primary health care team functioning and overall primary health care performance at Du Noon Community Health Centre

BACKGROUND

 Research consistently demonstrates the importance of effective team work for improving the quality of health care. We conducted a baseline measure of primary health care (PHC) team effectiveness and overall PHC performance at a primary care facility.

AIM

 To improve PHC team effectiveness and ultimately the quality and user experience of primary care at a community health centre (CHC).

SETTING

 Du Noon CHC in the southern and western substructure of the Cape Town Metro district services (MDHS).

METHODS

 A cross-sectional study using a combination of the Nominal Group Technique (NGT) consensus method and the South African Primary Care Assessment Tool (ZA PCAT) to assess PHC team effectiveness and PHC organisation and performance.

RESULTS

 The ZA PCAT was administered to 110 CHC users (patients) and 12 providers (doctors and clinical nurse practitioners). Data from 20 PHC team members showed they perceived their team as well functioning (70% agreement on a 7-item PHC team assessment tool incorporated into the ZA PCAT). The NGT method achieved participant (20) consensus on communication and leadership as the main challenges to effective team functioning and on ideas to overcome the challenges. The ZA PCAT user data showed 18.2% of users rated first contact access as acceptable to good; 47.3% of users rated ongoing care as acceptable to good. Provider data showed that 33% of providers rated first contact access as acceptable to good; 25% of providers rated ongoing care as acceptable to good. First contact access received the lowest acceptable to good score (18.2%) and comprehensiveness (services available) the highest score (88.2%) from users. For the providers, the lowest acceptable to good score was for ongoing care (25%) and the highest acceptable to good score was for primary health care team availability (100%). The ZA PCAT total primary scores were good (above 60%) for both users and providers but moderately higher for the providers.

CONCLUSION

 Knowledge of how teams perceive their effectiveness can motivate them to generate ideas for improving performance. There were discrepancies between providers' assessment of team functioning using the ZA PCAT measure and the NGT method results. The ZA PCAT also showed differences between providers' and users' perceptions of PHC performance - consistent with the findings of the multi-CHC Western Cape ZA PCAT study. These findings should encourage and support CHC and district level staff in their efforts to improve the quality and user experience of primary care, as well as PHC team performance.

Guiding Principles for Team-Based Pediatric Care

The American Academy of Pediatrics (AAP) recognizes that children's unique and ever-changing needs depend on a variety of support systems. Key components of effective support systems address the needs of the child and family in the context of their home and community and are dynamic so that they reflect, monitor, and respond to changes as the needs of the child and family change. The AAP believes that team-based care involving medical providers and community partners (eg, teachers and state agencies) is a crucial and necessary component of providing high-quality care to children and their families. Team-based care builds on the foundation of the medical home by reaching out to a potentially broad array of participants in the life of a child and incorporating them into the care provided. Importantly, the AAP believes that a high-functioning team includes children and their families as essential partners. The overall goal of team-based care is to enhance communication and cooperation among the varied medical, social, and educational partners in a child's life to better meet the global needs of children and their families, helping them to achieve their best potential. In support of the team-based approach, the AAP urges stakeholders to invest in infrastructure, education, and privacy-secured technology to meet the needs of children. This statement includes limited specific examples of potential team members, including health care providers and community partners, that are meant to be illustrative and in no way represent a complete or comprehensive listing of all team members who may be of importance for a specific child and family.