The 10 Building Blocks of High-Performing Primary Care

As primary care reemerges as the foundation for proper patient-centered care, new schemes must be established to foster the future success of such institutions. Based on personal clinical experiences and literature reviews of model patient centered medical homes, Thomas Bodenheimer et al establish an approach to forming an effective and adaptable practice. Expanding upon Starfield's four pillars of primary care, the authors describe 10 building blocks that can form a clinic that is efficient and rewarding to both patients and staff.

The first building block addressed in the article is engaged leadership, which not only emphasizes the importance of good leadership to facilitate change in an organization but also the importance of leadership at all levels. Leadership roles would be filled at all tiers of the healthcare staff. Our group agreed that the divide and conquer method is good for maximizing the efficiency of all clinic components, from receptionist to physician. However, it is important to establish overall leadership as well. Such a role would be responsible for creating primary, evidence based goals and objectives, which leadership at the various levels can strive to achieve in the scope of their own roles.

The second building block consisted of improving a practice based on tracking data related to clinical, operational, and patient satisfaction metrics. There was agreement in collecting performance data to put on display as a means to stimulate improvement amongst the staff, who become motivated to evaluate quality outcomes that are important to the patients and not just the providers. However, most of us had doubts on the use of such data as a method of performance evaluation, particularly if it came to an external comparison amongst clinics and the results having ties to reimbursement. Unlike keeping track of data for internal comparison, data tied to results used for clinic-to-clinic comparison may promote improper practices. A major concern in implementing this plan is the increased incentive to kick out non-compliant patients in such a scenario.

The third building block, empanelment, emphasized the need to connect a patient with a specific care team. The importance of empanelment comes in its role as the foundation for future building blocks such as establishing patient-team partnerships in block 5 and ultimately improving patient continuity in block 7. It is also critical for identifying patient populations in block 6. Although we agreed that empanelment is beneficial for adjusting the workload among clinicians and providing comfort for the patients, we ultimately felt that in the current primary care environment, the demand exceeds the capacity. In such an atmosphere, the patient is less attached to the provider and prefers convenience.

The fourth building block focused on team-based care, the premise of building a team consisting of a clinician and non-clinician staff to share the work of a patient's care. These teams consist of a clinician and clinical assistant teamlet, with which a nurse, a pharmacist, and other support staff support several teamlets. Our group saw the benefit in such a setup, particularly where trained non-clinician staff could manage maintenance of chronic conditions, thus allowing clinicians the flexibility to see more patients. From this model, a scenario where the physician and pharmacist, or other support staff, would see a patient together or back-to-back can be efficient for both the clinic and the patient. However, we discussed the limitations of such team setups at locations where staffing may be limited. Discussing team-based care leads us to block 5's patient-team partnership. This partnership values the inclusion of patients in their own medical decision making process and identifying the patient as a valuable team member. We fervently agreed that including the patients in decisions would broaden the knowledge of their disease, improve compliance, increase accountability, and establish a base for sustaining long-term lifestyle changes.

Population management is the focus of the sixth block, and it works by stratifying the needs of a patient population amongst various team roles. A great example that was mentioned in the article was addressing routine care by non-clinicians prior to being seen by the clinician. In addition, having chronic conditions maintained by trained educators and health coaches. This can free up clinician visits to discuss issues pertinent to the patient or that require clinician-level expertise. This method of preventing gaps in care is a great example of how the team-based care established with block 4 can be utilized.

Blocks 7 and 8 dealt with continuity of care and prompt access to care, respectively. Our group appreciated the dichotomy between these two blocks, as most patients must prioritize between timing of visits and the visiting physician. We agree that it is up to all staff to encourage patients in maintaining continuity, but we also understand the friction between the current shortages in primary care versus the high patient volumes. Because of this imbalance, it may be less beneficial for smaller or less staffed clinics to focus much time and resources on continuity.

The ninth block concerns coordinating care with medical resources external to the clinic. Properly handling the coordination of care is vital to maintaining thorough care of a patient and is important in sustaining a good clinic-patient relationship. Excellent coordination, which will necessitate a coordination team, allows for more efficient and streamlined care and can ultimately help patients decrease healthcare costs. Smooth coordination of care will allow for an easier implementation of block 10, a template of the future. This block emphasizes the transition from the typical 15-minute visit of the past to utilizing group appointments and embracing the importance of technology in healthcare. Protected time for e-visits and telephone encounters allows more accessibility for patients, especially those populations without easy access to care. We felt that many physicians are already incorporating electronic and telephone encounters into their practice, but since this time is not protected these encounters tend to be rushed or add significant more time to their workday.

Overall, we felt that Bodenheimer et al did a good job simplifying how to design a clinic that is adaptable to how primary care can be managed in the future. However, we did identify limitations. As the authors discuss themselves, smaller clinics were underrepresented in this article, despite a large portion of practices containing five or fewer physicians. They mention attributes to focus on, such as having a meaningful care team and proactively using population-based care. However, there is not much discussion on how smaller clinics can implement such practices with limited resources. In addition, we would like to have seen data comparing clinics implementing the 10 building block method to those with less integration to observe any significant changes in patient health short- and long-term outcome. For future discussion, we would also like to see a further breakdown of the building blocks, addressing the challenges and implementation strategies with individual blocks for clinics of various sizes and resources. Despite our proposed limitations, the 10 building blocks present a new starting point to help recreate primary care in the future.

Competing interests: None declared