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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Teamlets are fact, not theory
A Health Coach’s Lens on Eliciting Change Talk in Primary Care
Good idea... but will it work today?
role of health coach
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Michael K. Magill, Salt Lake City, Utah Professor and Chairman, Department of Family and Preventive Medicine, Univ of Utah Sch of Medicine
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The teamlet model Bodenheimer describes already exists and is rapidly evolving in multiple family medicine practices of many types across the nation: small private practices, large groups, Community Health Centers, and academic. It is being driven by the palpable change in efficiency, quality, and satisfaction for patients, staff and providers who experience it. We have developed a similar model in the University of Utah Community Clinics, an 11-site, 100-provider multidisciplinary practice network caring for over 125,000 active patients. We have tested the model in our smaller practices and are now implementing it over time in all our sites. Along the way, we have learned some lessons that add to Bodenheimer’s excellent description of the model: • It is useful to think of the role of the health coach (in our case, a medical assistant (MA) with advanced training) as delivering the visit to the patient. An MA greets a patient on arrival (no receptionist, no waiting), verifies identifying and insurance information, and takes the patient to an examination room where the MA immediately begins the clinical visit (a similar model is described in Gordon P, Chin M. Achieving a New Standard in Primary Care for Low-Income Populations: Case Study 1: Redesigning the Patient Visit, The Commonwealth Fund, August 2004, http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=235281#areaCitation, accessed November 3, 2007). Delivering the visit to the patient in the room and never abandoning the patient dramatically reduces patient cycle time in the office (Endsley S, Magill MK, Godfrey MM. Creating a Lean Practice. Fam Pract Mgmt April 2006: 34-8). • Advanced training for MAs can go farther than we might have imagined. In our case, MAs register patients, scribe histories and physical examinations using an extensive library of computer-based templates, draw blood, take xrays under a limited radiology technician license, explain computerized after visit summaries.to patients, schedule follow-up appointments, and maintain contact with patients such as those due for chronic disease management or health maintenance. This is consistent with the pattern of “up-migration” of disciplines over time described by Christensen. (Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations save health care? Harvard Business Review Sep-Oct 2000: 20-8.) • With an adequate supply of MAs, the practice maintains the same staff to physician ratio and overhead as do traditional model practices, with MAs replacing staff who had served other, more limited roles. Ideally, the teamlet-based practice has 5 MAs to 2 physicians, eliminating need for receptionists, phlebotomists, and medical records personnel. In our setting, this is further supported by an off-site call center and robust electronic health record (EHR). It’s amazing how helpful it is for the telephone not to ring while the teamlet cares for patients. Response time to patient calls for clinical issues is actually reduced, as messages flow efficiently through the EHR messaging function. • With an adequate ratio of MAs to providers, physician time with patients flows smoothly. The physician is no longer the bottleneck for the practice. But neither is the MA. When a relatively complicated, talkative, or distressed patient arrives, a single MA can devote as much time to the patient as needed, while the other MAs and providers maintain flow of patients through the practice. When the more complex patient is prepared to see the provider, the actual provider time required is not much different from that for other patients. One of our physicians describes this as analogous to a railroad siding. The MA and the patient needing extra time spend as much time as needed on the siding, while the main line traffic continues to flow. Once ready, the patient from the siding re-enters the mainline without interruption. • Training and retention of health coaches is a rate limiting step for implementation of the teamlet. In our area, no training program provides MAs with all the skills. We have therefore developed our own training program. Small practices may be vulnerable to turnover of the health coaches: absence or loss of just one or two causes breakdown of the model. Large groups such as ours may offer flexible coverage, but at the price of more difficulty standardizing provider and MA roles across teams. Competing interests: None declared |
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Judith Doherty, West Boylston, MA, USA Health Coach
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In clinical practice it seems a delicate balance must be struck between short-changing patients by cutting off their stories, and having appointments become unwieldy. The dilemma seems to be how to respond to material that patients bring to the clinic, and at the same time, nudge them in the direction of healthier living. I am impressed by Dr. Thomas Bodenheimer’s essay “The Teamlet Model of Primary Care” Annals of Family Medicine (2007) in that the previsit/postvisit structure adds focus to the work of a health coach and assists the physician in meeting patients’ needs. When a health coach meets prior to the physician visit, the patient can feel heard and can focus on agenda setting. Likewise, the health coach can direct the patient in particular ways to insure that time with the doc answers important questions. The post visit talk can support and recap important elements from the physician encounter. Having worked with over 100 patients in the role of health coach, I’ve determined that “vital conversations” can occur, when a coach emphasizes the following in the previsit:
Limiting Unproductive Talk by steering patients back to their own core issues is not only time efficient; it also helps them to center on what is most important. Due to nervousness, patients can wander in medical conversations wondering which aspects are significant to share. The health coach can gently guide by looping back to synthesize and pulling a thread of conversation through that seems central. In Dr. Bodenheimer’s “teamlet model” the health coach would often participate in the physician visit. In my view patients should be explicitly asked whether they prefer only to have the health coach pre and post, but not in the examination room. Combining the Bodenheimer and Laing “teamlet model of primary care” with attention to the how of conversations with health coaches could offer more satisfying patient, health coach and physician encounters seems a valuable direction in health care. Competing interests: None declared |
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David V Garrett, Leawood, US Medical Practice Facilitator, TranforMED
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I feel the article does a great job of identifying the growing complexity of today’s primary care office visit, in addition stating that the traditional approach of 15 minute ambulatory visits no longer satisfy the needs of the patient or provider team. Such visits may be fine for acute care or basic medication management, but tend to be inadequate for those with a chronic issue(s) or multiple conditions. The “teamlet” approach as outlined in your article is intriguing in that it accomplishes some critical things. It more appropriately assigns important parts of the visit such as information intake, medication reconciliation, standing orders for diagnostic management, and patient coaching, to non-physician staff. With these things done and documented, the physicians can concentrate on further high level assessment, asking clarifying questions and building a relationship with each patient. Just as important, the post-visit is critical and something that is not being done in today’s office exams. The entire visit is of minimal use if the patient doesn’t understand why they were treated, what was done, and how they should incorporate changes into their daily life. If there were 2 coaches per provider to keep the provider moving, and another team member (possibly RN) working on patient triage and follow-up from the previous day(s), I think such a model could work. The article does well to point out that changes to the current model will be short lived as this approach is unsustainable in the current reimbursement system outside of academic centers. I would enjoy seeing multi-year studies to prove the long term cost effectiveness of such a model. I think it would also produce better patient outcomes, happier physicians and staff. Competing interests: None declared |
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Melinda H. Huffman, Winchester, TN Principal, Miller & Huffman Outcome Architects, LLC
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I applaud Bodenheimer and Laing for introducing the teamlet approach as a way to enhance the efficiency of family practice and the patient experience. I recommend that greater consideration be given to the role of health coach as one who guides the patient through self-discovery of amibvalence to health behavior change; a key component of successful chronic condition management. An action plan may yield better outcomes when coupled with health coaching strategies to assist patients in changing health behaviors. Competing interests: None declared |
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