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Research ArticleSpecial Report

Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers

Erin Fries Taylor, Rachel M. Machta, David S. Meyers, Janice Genevro and Deborah N. Peikes
The Annals of Family Medicine January 2013, 11 (1) 80-83; DOI: https://doi.org/10.1370/afm.1462
Erin Fries Taylor
1Mathematica Policy Research, Princeton, Washington, DC
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  • For correspondence: etaylor@mathematica-mpr.com
Rachel M. Machta
2Center for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, Maryland
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David S. Meyers
2Center for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, Maryland
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Janice Genevro
2Center for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, Maryland
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Deborah N. Peikes
1Mathematica Policy Research, Princeton, Washington, DC
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  • Practice Transformation in Medicaid
    Dianne Hasselman
    Published on: 13 February 2013
  • Insights into team-based primary care
    Eric K. Shaw
    Published on: 04 February 2013
  • Tackling Role Ambiguity: Practice Facilitator vs. Care Manager
    Neill B. Baskerville
    Published on: 18 January 2013
  • Practice Facilitation - Reflections On 14 Years' Experience
    Zsolt J Nagykaldi
    Published on: 18 January 2013
  • Published on: (13 February 2013)
    Page navigation anchor for Practice Transformation in Medicaid
    Practice Transformation in Medicaid
    • Dianne Hasselman, Director, Quality and Equality

    Your article on practice facilitators and care managers was very accurate in terms of delineating roles and reminding us why both types of professionals are vital for transforming the way care is delivered in the US.

    These professionals are critical for primary care practices - particularly smaller ones - that serve a large proportion of low-income patients.[1] These practices are often under-resourced, disen...

    Show More

    Your article on practice facilitators and care managers was very accurate in terms of delineating roles and reminding us why both types of professionals are vital for transforming the way care is delivered in the US.

    These professionals are critical for primary care practices - particularly smaller ones - that serve a large proportion of low-income patients.[1] These practices are often under-resourced, disenfranchised from the larger health care delivery system, and excluded from quality improvement initiatives for a variety of reasons.[2] Low-income patients often present an overwhelming array of medical, behavioral, and social challenges that small provider practices may be unequipped to address. Quality of care often suffers as a result.

    The good news is that Medicaid, as the largest purchaser of health care for Americans, has the opportunity to address that disparity. Through opportunities under the Affordable Care Act, states can provide care management teams that bring much-needed reinforcements through care coordination, care transitions, health promotion and other "health home" services.[3] These services not only help practices manage their most complex patients, but they can reduce costly and avoidable services like inpatient admissions, readmissions, emergency room visits, and nursing home stays. States like Missouri, New York, and Oregon provide excellent examples of this effort.

    Medicaid can also leverage its purchasing power to support practice facilitators and other quality improvement assistance at the practice level. Medicaid programs in North Carolina and Oklahoma deploy quality improvement coaches to practices with a high percentage of Medicaid patients to assist with patient registry implementation, quality measurement, and practice redesign. As a result, the practices have an opportunity to become less chaotic, more efficient, and better equipped to provide quality care.

    As 2014 draws closer, potentially adding 11 million Americans into our health care insurance system,[4] this is the time to double down and invest in our primary care safety net. Medicaid can serve as a leader in showing other payers how to do this.

    1. Moon J., Weiser, R., Highsmith, N., Somers, S. The Relationship Between Practice Size and Quality of Care in Medicaid, July 2009.
    2. Advancing Primary Care: Opportunities to Support Care Delivery Redesign in Practices Serving Medicaid and Racially and Ethnically Diverse Patients, August 2012.
    3. Section 2703 of the Affordable Care Act.
    4. Congressional Budget Office and Joint Committee on Taxation. Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision. July 2012.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (4 February 2013)
    Page navigation anchor for Insights into team-based primary care
    Insights into team-based primary care
    • Eric K. Shaw, Associate Professor

    Thank you to Taylor et al. for this special report that continues to expand our current understandings and conceptions of these roles in primary care. This work addresses the complex nature of developing primary care teams. Having clearer understandings of facilitator/care manager roles and how they fit into the 'whole' is vitally important.

    This report also highlights some interesting points about primary c...

    Show More

    Thank you to Taylor et al. for this special report that continues to expand our current understandings and conceptions of these roles in primary care. This work addresses the complex nature of developing primary care teams. Having clearer understandings of facilitator/care manager roles and how they fit into the 'whole' is vitally important.

    This report also highlights some interesting points about primary care team functioning. Developing strong relationships (with practice members, patients, community resources, etc.) are fundamental to both of these roles. Indeed, the authors emphasize the importance of trust and effective communication for relationship building and there is extensive research both within the healthcare literature and more broadly that supports this claim. But these roles do have different functions. Facilitation is more about the process of change - having tools, skills, and competencies to facilitate effective communication, build teamwork, and develop a culture of change. It could be said, then, that care management is more about the content (e.g., improving diabetes care) that is being focused on. While this distinction does not necessarily reflect an automatic division of labor (and skills or competencies) between facilitators and care managers, the authors' push to consider the synergies between these roles on a team is quite valuable.

    I also appreciated the commentaries on this article. In particular, Dr. Nagykaldi noted the ongoing developments for a national facilitator training curriculum. Facilitators should be skilled in handling group dynamics and conflict, managing meetings, building a sense of 'teamness,' etc. Developing such competencies requires time and training. Existing models such as that of the International Association of Facilitators may provide some insights for these efforts. While not geared towards primary care or health care, this organization has a well-established curriculum, tools, etc. for developing core competencies in facilitation.

    Lastly, I'll emphasize that the work by Taylor et al. serves as a call for additional research on this area. Ethnographic research approaches would be ideal to understand what it looks like when teams have both a facilitator and care manager working on a quality improvement project over time. How do their roles overlap? How do they rely on and communicate with one another (and others)? How do such team efforts affect desired outcomes? Developing an evidence-base for understanding some of these 'how' questions may put efforts to transform care and maintain quality improvements on even more solid footing.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (18 January 2013)
    Page navigation anchor for Tackling Role Ambiguity: Practice Facilitator vs. Care Manager
    Tackling Role Ambiguity: Practice Facilitator vs. Care Manager
    • Neill B. Baskerville, Senior Scientist

    I thoroughly enjoyed reading the article by Taylor and colleagues on the roles of practice facilitators and care managers. There has been more than 20 years of practice-based research on facilitation. Despite this I have experienced numerous occasions in my own research where questions have been raised about the differences or benefits of an external versus an internal practice facilitator as well as ambiguity about the...

    Show More

    I thoroughly enjoyed reading the article by Taylor and colleagues on the roles of practice facilitators and care managers. There has been more than 20 years of practice-based research on facilitation. Despite this I have experienced numerous occasions in my own research where questions have been raised about the differences or benefits of an external versus an internal practice facilitator as well as ambiguity about the role of practice facilitators. Taylor and colleagues' contribution brings greater clarity and a logical framework for understanding the distinct and complementary roles of practice facilitators and care managers in improving primary care delivery.

    The article also highlights the important issue of sustainability for practice facilitation services. Many jurisdictions are struggling to support and sustain practice facilitation efforts that have to-date been funded primarily as pilot projects with sunset funding. As more context specific evidence on the success of primary care quality improvement initiatives, such as practice facilitation and the patient-centered medical home in the US, is shared with engaged stakeholders and policy- makers -- sustainability will be less of an issue.

    I will certainly be citing Taylor and colleagues in future publications on practice facilitation and systems level approaches to improving the implementation of evidence-based practices.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (18 January 2013)
    Page navigation anchor for Practice Facilitation - Reflections On 14 Years' Experience
    Practice Facilitation - Reflections On 14 Years' Experience
    • Zsolt J Nagykaldi, Associate Professor, Network Coordinator

    I applaud this, yet another, great article on Practice Facilitators (PFs). We have really come a long way! In 2000, marking the new millennium, the Oklahoma Physicians Resource/Research Network (OKPRN) hired its first facilitator called a Practice Enhancement Assistant (PEA). Facilitation was hardly new even back then: we borrowed heavily from the British model going back to the early 1980's. Some other networks in the U...

    Show More

    I applaud this, yet another, great article on Practice Facilitators (PFs). We have really come a long way! In 2000, marking the new millennium, the Oklahoma Physicians Resource/Research Network (OKPRN) hired its first facilitator called a Practice Enhancement Assistant (PEA). Facilitation was hardly new even back then: we borrowed heavily from the British model going back to the early 1980's. Some other networks in the U.S. and in other countries (e.g., Canada) also employed professionals in a similar capacity, but the concept had very little public traction. Only a few facilitators worked in silos, usually not knowing about each other.

    It took the grass-roots "facilitator movement" some time to attract attention. By 2005, we saw a handful of PFs discussing and sharing their experiences at national AAFP and AHRQ conferences. Systematic dissemination of the idea of facilitation, inclusion of PFs in grants, contracts, and various quality improvement activities in the next 5-8 years resulted in a proliferation of PF "implementations", albeit with some varieties in the shared understanding of the PF role. All along PFs, understanding their own potential, wondered when facilitation might become a recognized and certified profession.

    The past 2-3 years have been pivotal in the evolution of practice facilitation in America. Most importantly, federal and state agencies have taken tangible steps to usher the process by specific inclusion of PFs in RFAs/PAs, dedicating funding for research that gauged the impact of facilitation, and the publication of a nationally distributed practice facilitation program manual by AHRQ. At the time of this commentary, several invested PBRNs are also developing a national training curriculum that will provide a college-level certification path for facilitators. This will greatly enhance the standardization of training and the general acceptance of PFs as practice development professionals.

    Another exciting opportunity for PFs to evolve their role includes the emerging establishment of a national health extension infrastructure (IMPaCT grants) that may help expand their role to community-level coordination of health and wellness services as health extension agents. We believe that these improvements will provide a new and exciting infrastructure, for the first time in the United States, to effectively and expeditiously disseminate new knowledge and innovations to primary care stakeholders and thus accelerate the "bench-to-bedside" translation loop.

    Working side-by-side with primary care-integrated care managers is also a fresh idea that will undoubtedly improve care coordination and health coaching, simultaneously touching both domains of health improvement: the patient and the practice.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 11 (1)
The Annals of Family Medicine: 11 (1)
Vol. 11, Issue 1
January/February 2013
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Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers
Erin Fries Taylor, Rachel M. Machta, David S. Meyers, Janice Genevro, Deborah N. Peikes
The Annals of Family Medicine Jan 2013, 11 (1) 80-83; DOI: 10.1370/afm.1462

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Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers
Erin Fries Taylor, Rachel M. Machta, David S. Meyers, Janice Genevro, Deborah N. Peikes
The Annals of Family Medicine Jan 2013, 11 (1) 80-83; DOI: 10.1370/afm.1462
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