Perspective

Lessons from the Trenches — A High-Functioning Primary Care Clinic

Thomas Bodenheimer, M.D.

N Engl J Med 2011; 365:5-8July 7, 2011

Article

Clinica Family Health Services is a community health center serving a low-income, largely Latino population near Denver. Since its inception 30 years ago in founder Alicia Sanchez's kitchen, Clinica has grown to serve 40,000 patients at four sites. Fifty percent of these patients are uninsured; 40% have Medicaid. Like many community health centers, Clinica is financed by augmented Medicaid fees, federal grants, sliding-scale payments from uninsured patients, and energetic local fundraising.

Clinica's story reveals that U.S. primary care is undergoing two revolutions. The first, catalyzed by the Chronic Care Model, targets specific diseases such as diabetes or asthma. The second, coming on the heels of the first, entirely transforms primary care delivery. Starting in 1998, Clinica was an activist in the first primary care revolution with its work on diabetes. After 2000, Clinica initiated the second revolution, redesigning its entire care model to become a patient-centered medical home. Clinica's experience demonstrates how such medical homes can be constructed out of three fundamental building blocks — continuity of care, prompt access to care, and care provided by teams — and the ways in which primary care practitioners (physicians, nurse practitioners [NPs], and physician assistants [PAs]) adapt to the resulting changes in their work life.

Clinica's medical director, family physician Carolyn Shepherd, grasped early on that continuity of care between patients and their primary care practitioner is associated with better preventive and chronic care, improved experiences for both patient and practitioner, and lower costs.1 Implementing a culture of continuity requires that patients be assigned to the panel of a specific practitioner, who is available most days of the week. These clinicians must be willing to squeeze their patients — but not other clinicians' patients — into their schedules if same-day attention is needed. Staff members answering the phone must prioritize such continuity.

If achieving continuity is like climbing a 5000-ft mountain, sustaining prompt access to care is like scaling one of Colorado's 14,000-ft peaks. For 10 years, Clinica has provided most appointments within 6 days of patients' requests, and usually within 2 days. Clinica fills primary care practitioners' schedules from 8 a.m. to 10 a.m., leaving many slots for same-day access. Staff members who answer the phones are not allowed to say no to patients, whose requests are addressed with appointments, “squeeze-ins,” or visits with a registered nurse (RN). Schedules are created for only 2 weeks at a time, to ensure that appointment slots will remain open. If clinicians request appointments for their patients beyond the next 2 weeks, electronic reminders generate calls to those patients on the appropriate date.

Adequate access requires an equilibrium between demand for visits and capacity to provide them. At Clinica, this balancing act is accomplished by eliminating unnecessary demand and adding capacity. Continuity of care reduces demand because if patients see other clinicians, an additional appointment is often scheduled with their own clinician for the same problem.2 Demand is also reduced by increasing the intervals between visits, which has been shown in most cases not to harm the quality of care.3 Capacity is increased by offering patients visits with RNs for less complex problems and through group visits, which allow clinicians to see 30 to 40% more patients per hour.

Embracing continuity and improved access requires clinicians to accept a truly patient-centered approach to care: to see patients most days of the week, to cede to their patients control over their daily schedules, and to be willing to see their own patients who drop into the office and not expect other clinicians to do so. Why might clinicians agree to such changes in their work life? Clinica's practitioners have accepted the priorities of continuity and access partly because persuasive medical leaders had the courage to say “this is the way it's going to be,” partly because they see these policies benefiting their patients, and recently because Clinica has been recruiting new clinicians who already agree with these principles.

Clinica has moved boldly from a doctor-based model to a team-based model.4 All clinical activity centers around the “pod” (care team), which includes at one location three primary care practitioners and three medical assistants (MAs, each working with a single clinician), plus an RN, a case manager, a behavioral health professional, and medical-records and front-desk staff. Clinicians don't have their own offices; each pod has a central area surrounded by exam rooms. Pod members easily interact with one another and can see all patient rooms, whose doors are marked with colored flags showing who is inside. In each pod, performance data are displayed on a wall, and any deficiencies are discussed at team “huddles.” Clinica's quality of care often exceeds national Medicaid performance (see tableClinica's Performance Data (as Compared with Average 2009 HEDIS Scores for All Medicaid Health Plans, Where Available).) — especially impressive given that Clinica's data include the 50% of its patients who have no insurance.

Every team member shares responsibility for the team's patients. MAs take histories using electronic medical record (EMR) templates and give immunizations according to protocols, without involving physicians, NPs, or PAs. Designated team members handle most preventive and much chronic care through panel management — combing registries and arranging for patients who are found to be overdue for mammograms, colorectal cancer screening, or diabetes laboratory work to receive these services. RNs, using standing orders, treat patients with ear infections or positive streptococcal, urine, gonorrhea, or chlamydia cultures and manage warfarin dosing — all without involving primary care practitioners, who sign off later in the EMR. As much as possible, clinicians spend their time providing complex diagnosis and management, with routine functions performed by other team members. Only through a team approach can primary care, with its clinician shortage, meet population-wide needs.

To make the transition to team care, Clinica reconfigured hundreds of workflows, detailing who would do what and how, for such functions as receiving incoming phone calls, updating clinician schedules, informing patients of laboratory results, and refilling prescriptions. For common clinical conditions and well-child care, specific workflows were created and job roles were redefined using standing orders, with the goal of standardizing guideline-driven care while dividing responsibility among team members.5

Team-based care requires fundamental changes in clinicians' mindset. Many practices claim to have teams, but the physician provides all care and delegates specific tasks (fax this form, do an EKG) to others. At Clinica, the entire team shares responsibility for the health of the patient panel. Entire work areas, though overseen by an MD, NP, or PA, are performed independently by RNs, MAs, or case managers. For clinicians to accept this shift from “I” to “we,” team members must have their roles authorized through protocols and be trained to perform them competently. Clinicians must have confidence that all team members are doing a good job in order to feel relief that they have time for more complex tasks.

Clinica will next focus on controlling costs by reducing unnecessary emergency department visits and hospital admissions. Achieving this goal will require a deepening of team care, with care managers assisting patients who have complex, high-cost conditions. This step awaits a new funding stream, which requires participation in an accountable care organization in which Clinica will share the savings from reduced downstream costs.

Clinica has confronted basic primary care challenges and answered key questions: How can continuity of care be made the centerpiece of a medical practice's ethos? Can a policy of providing prompt access be sustained? Who should be included in care teams, who should perform which work, and how central to team function are colocation, workflows, and standing orders? How should care for common conditions be standardized?

Ultimately, clinicians' acceptance of the primary care revolutions will be sustainable only if their work life is more satisfying than it was before. Understanding that necessity, Clinica's leaders have created an organization that serves patients well while retaining a group of loyal clinicians.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Source Information

From the Center for Excellence in Primary Care in the Department of Family and Community Medicine, University of California, San Francisco, School of Medicine, San Francisco.

References

References

1. 1

   Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med 2005;3:159-166
   CrossRef | Web of Science | Medline

2. 2

   Murray M, Tantau C. Same-day appointments: exploding the access paradigm. Fam Pract Manag 2000;7:45-50
   Medline

3. 3

   Schectman G, Barnas G, Laud P, Cantwell L, Horton M, Zarling EJ. Prolonging the return visit interval in primary care. Am J Med 2005;118:393-399
   CrossRef | Web of Science | Medline

4. 4

   Bodenheimer T. Building teams in primary care: lessons learned: parts 1 and 2. Oakland, CA: California Health Care Foundation, July 2007. (http://www.chcf.org/publications/2007/07/building-teams-in-primary-care-lessons-from-15-case-studies.)
   

5. 5

   Details of Clinica's care model (“Clinica Family Health Services”) are available at http://familymedicine.medschool.ucsf.edu/cepc.
   

Citing Articles (2)

Citing Articles

1. 1

   Lisa Ross DeCamp, Edith Kieffer, Joseph S. Zickafoose, Sonya DeMonner, Felix Valbuena, Matthew M. Davis, Michele Heisler. (2012) The Voices of Limited English Proficiency Latina Mothers on Pediatric Primary Care: Lessons for the Medical Home. Maternal and Child Health Journal
   CrossRef

2. 2

   John I. Allen. (2012) Gastroenterologists and the Triple Aim: How to Become Accountable. Gastrointestinal Endoscopy Clinics of North America 22:1, 85-96
   CrossRef