Quality, Satisfaction, and Financial Efficiency Associated With Elements of Primary Care Practice Transformation: Preliminary Findings

The University of Utah Community Clinics is one of the larger and most mature examples of team-based, patient-centered primary care redesign. While many such efforts fall by the wayside due to leadership turnover and staff/provider resistance, the Utah group has been able to stay the course because they have the will and the tools to examine and adjust their practice over time. Emerging from a very tenuous beginning, Care by Design is now accepted as the primary care practice model at the University of Utah Health System. This early disruptive innovation has had to flex and grow to accommodate a new challenge: success and institutionalization.

The Care by Design uses care teams with a high medical assistant(MA)- to-provider ratio. MAs in this model stay with the patient through the visit, from check-in through discharge, often scribing through the exam. At some sites, spatial design, including co-location has been deployed to enhance the team model. Through their EHR, University of Utah clinics use scripted protocols ("X-files") to delegate some work to MAs and other non- provider staff. MAs also have some opportunities for career advancement in this model, based on their acquisition of additional skills and training as needed by their practice sites.

Our recent work at the Center for the Health Professions at UC San Francisco, with funding from the Hitachi Foundation, has focused on innovative workforce models that utilize MAs in expanded roles that a) improve patient care, b) maintain or improve organizational efficiency, and c) provide career advancement or enhancement for MAs. One thing that has been a particular challenge in our work is obtaining the data that document the impact of these models, particularly data on which impacts can be attributed to changing the roles of frontline staff like medical assistants.

University of Utah was one of our case study sites although, when we visited, the data used in the study just published was not yet available. Like several high-performing organizations we visited, Utah is delegating routine tasks to frontline staff, using scripted protocols in the EHR to guide non-licensed staff through various patient education functions. These elements should relieve some of the work burden of providers, freeing them to spend more focused time with the patient, and further engage the MA in patient care. It was surprising to us that the Utah researchers found a negative correlation between patient satisfaction and the use of templated questionnaires. The reasons behind the finding are unknown at this point and could range from relatively benign questionnaire design to substantive flaws in the way staff are interacting with patients. The University of Utah's work prompts us all to look closer at what document revisions, training, or workflow change would make these elements of the encounter a success in terms of patient satisfaction.

The researchers found positive correlations between MA engagement and quality measures, and MA continuity and patient satisfaction. These findings suggest that the team approach, including expanding the role of frontline staff, can enhance not only patient satisfaction, but clinical outcomes. The connection between huddles and quality measures further reinforces the idea that the team approach is reliant on effective and systematic communication between all team members. That overall continuity of care is a key factor in patient satisfaction also suggests that strategies to enhance staff retention may be valuable in implementing the medical home, a finding that has been repeatedly brought to our attention through the course of our case studies work.

The University of Utah researchers have helped to further unpack the components of the medical home and examine how and whether they influence the desired outcomes. The attention to the role of different team members in affecting these outcomes is particularly timely as the nation moves to implement the Affordable Care Act, which will require the most efficient deployment of our health care workforce to meet the needs of a growing population newly insured patients.

Competing interests:   None declared