WHAT DOES TEAM LEADERSHIP MEAN IN THE PCMH?

A decade ago, the Future of Family Medicine report supported the development of a new model of practice.¹ This model quickly evolved into a clinical care entity known as the Patient-centered Medical Home (PCMH). There was much synergy for the new PCMH model between the primary care community and the business community. Paul Grundy, IBM Corporation’s Global Director of Healthcare Transformation, in concert with 4 practicing physician organizations, led a movement to identify the PCMH model as the cornerstone of a new organization, the Patient-Centered Primary Care Collaborative (PCPCC). A critical step to catalyzing the PCPCC in 2007–2008 was defining the Joint Principles of the Patient Centered Medical Home adopted by the 4 professional societies who came together to form the PCPCC (the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association). These joint principles were then endorsed by more organizations in family medicine including the Association of Departments of Family Medicine (ADFM).

Since its release, one of the principles in the original language of the joint principles of the medical home has been a source of controversy causing ADFM leadership to evolve in our thinking²:

“Physician-directed medical practice—the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.”

It is also noteworthy that the landscape of the “physician’s practice” has changed with far fewer physician-owned solo practices today than were in existence a decade ago.

In early 2014, ADFM, along with our sister academic family medicine organizations in the Council of Academic Family Medicine (CAFM): the Association of Family Medicine Residency Directors (AFMRD), the North American Primary Care Research Group (NAPCRG), and the Society of Teachers of Family Medicine (STFM), published “The Four Pillars of Primary Care Physician Workforce Reform: A Blueprint for Future Activity.”³ The AAFP and ABFM collaborated with CAFM to approve the “four pillars” concept featured in this publication. A notable bullet in the four pillars model under practice transformation states:

“Practice teams must include generalist physician leaders who serve as role models, and who deliver comprehensive, broad-scope primary care.”

The language contained within this bullet was very intentional to mean that generalist physician leaders were to be on teams among other health professional leaders. Leadership within teams is 1 of the 4 core skills to great team functioning and should not imply a hierarchical structure.⁴ In fact, these same teams should also include other leaders such as nurses, nurse practitioners, social workers, pharmacists, and psychologists, to name a few. With effective teams, leadership skills should be practiced by all members of the team—along with the other core skills of mutual support, clear communication, and situation monitoring in the work environment.⁵ Our interpretation behind the intent of the four pillars language is in alignment with the sentiments expressed recently by Dr. Denise Rodgers, MD, FAAFP, Vice Chancellor for Interprofessional Programs and Director of the Rutgers Urban Health and Wellness Institute, Rutgers Biomedical and Health Sciences. In her plenary address, “Partners in Training: Interprofessional Education,” at the 2014 ADFM Winter meeting, Dr. Rodgers commented that in a given clinical care situation, the physician may be more remotely connected to a team led by another health professional. There are times when the physician will be at the front of the team. There are other times when the physician will step back and not be the central driver of the team’s activity, but ready to enter into the clinical care decision making when, and if, needed and willing to play a supportive role.

Leadership is often interpreted to mean a position of being “at the helm” in command at all times. True leadership happens at many levels and is often enacted more remotely. How we define and interpret the meaning of leadership on clinical care teams in the PCMH is a critical conversation to have among health professionals as we move together to achieve the Triple Aim⁶ for the American public.

This commentary has been prepared by members of the ADFM Executive Committee who were serving on the Council of Academic Family Medicine (CAFM) at the time “The Four Pillars for Primary Care Physician Workforce Reform: A Blueprint for Future Activity” was written.

• © 2014 Annals of Family Medicine, Inc.