Practice Environments and Job Satisfaction in Patient-Centered Medical Homes

Shehnaz Alidina; Meredith B. Rosenthal; Eric C. Schneider; Sara J. Singer; Mark W. Friedberg

doi:10.1370/afm.1662

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Primary Care Transformation Pre-Payment Reform: Is it possible?
Laurie M. Bauer

Published on: 12 August 2014
The Missing Metric: The Experience of the Care Team in PCMH Transformation
Nwando Olayiwola

Published on: 25 July 2014

Published on: (12 August 2014)
Page navigation anchor for Primary Care Transformation Pre-Payment Reform: Is it possible?
Primary Care Transformation Pre-Payment Reform: Is it possible?
Laurie M. Bauer, Senior Practice Coach
Primary care practice transformation is well underway in the US, even though payment models are not yet aligned to support many innovations in care. Is practice transformation that will increase clinician satisfaction possible before payment reform?
With the implementation of the Affordable Care Act, the influx of patients is stressing an already overburdened system, contributing to primary care clinician frustr...
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Primary care practice transformation is well underway in the US, even though payment models are not yet aligned to support many innovations in care. Is practice transformation that will increase clinician satisfaction possible before payment reform?
With the implementation of the Affordable Care Act, the influx of patients is stressing an already overburdened system, contributing to primary care clinician frustration. Some transformation strategies, such as advanced access, which may promote same day access to the practice at the expense of continuity with a patient's primary care provider, can lead to further clinician dissatisfaction. For example, Alidina et al. found that the anticipated clinician benefits of medical homes might be offset by the resulting chaos and stress of transformational change (1). Strategies aimed at reducing clinician stress; such as reducing panel size and lengthening visit length are not widely used because current incentives do not support reducing office visit volumes.
At the University of California, San Francisco's Center for Excellence in Primary Care we use the Ten Building Blocks of High-Performing Primary Care model (2) to facilitate practice transformation in San Francisco safety net clinics. In our work as practice coaches, we find that the move to team-based care is a key strategy to increase clinician satisfaction. Clinics that focus on adding capacity by sharing clinical care among the team often see improved access, higher quality of care and greater clinician satisfaction (3, 4, 5).
Teams that work well together have been shown to be associated with lower clinician burnout (6). Many practices that we work with are building capacity by transforming the roles of medical assistants and nurses. Pairing clinicians with consistent medical assistants ("teamlet-model") promotes team functioning, increases efficiency, and increases clinician and team satisfaction (7). Medical assistants conduct panel management within their teams, increasing accountability and team affiliation. Some clinics are using scribes to reduce the burden of electronic documentation. Incorporation of nurses in the team to address routine chronic care and uncomplicated conditions further increases capacity and frees up clinicians to focus on more complex patients.
Fortunately, in January 2015, Medicare will introduce a new payment code to reimburse clinicians for the care management of patients with multiple chronic conditions, including non-face-to-face visits (8). It is anticipated that other payers, including Medicaid, will follow suit. Practices preparing for transformation will benefit by strengthening team functioning and preparing for expanded and new roles for team members as they anticipate payment reform.
(1) Alidina S, Rosenthal MB, Schneider EC, Singer SJ, Friedberg MW. Practice Environments and Job Satisfaction in Patient-Centered Medical Homes. Ann Fam Med 2014; 331-337.
(2) Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 Building Blocks of High-Performing Primary Care. Ann Fam Med 2014; 166-171.
(3) Ghorob A, Bodenheimer T. Sharing the Care to Improve Access to Primary Care. N Engl J Med 2012; 366; 1955-1957.
(4) Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer. In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices. Ann Fam Med 2013; 11:272-278.
(5) Shaw RJ, McDuffie JR, Hendrix CC, Edie A, Lindsey-Davis L, Nagi A, Kosinski AS, Williams JW. Effects of Nurse-Managed Protocols in the Outpatient Management of Adults With Chronic Conditions Ann Intern Med. 2014;161:113-121.
(6) Willard-Grace R, Hessler D, Rogers E, Dube K, Bodenheimer T, Grumbach K. Team Structure and Culture are Associated with Lower Burnout in Primary Care. J Am Board Fam Med 2014;27: 229-238.
(7) Bodenheimer T, Laing BY. The Teamlet Model of Primary Care. Ann Fam Med 2007;5:457-461.
(8) Bindman AB, Blum JD, Kronick R. Medicare payment for chronic care delivered in a patient-centered medical home. JAMA. 2013 Sept 18; 310(11):1125-6.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (25 July 2014)
Page navigation anchor for The Missing Metric: The Experience of the Care Team in PCMH Transformation
The Missing Metric: The Experience of the Care Team in PCMH Transformation
Nwando Olayiwola, Associate Director
For many years, we have been following the evolution of the Patient-Centered Medical Home from a conceptual model to a practical tool for primary care transformation. This transformation, however, has not come without costs, be they financial, intellectual, operational, professional or cultural. Recently, I collaborated with the Patient-Centered Primary Care Collaborative on its annual review of PCMH-related studies and...
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For many years, we have been following the evolution of the Patient-Centered Medical Home from a conceptual model to a practical tool for primary care transformation. This transformation, however, has not come without costs, be they financial, intellectual, operational, professional or cultural. Recently, I collaborated with the Patient-Centered Primary Care Collaborative on its annual review of PCMH-related studies and reported impact on Triple Aim goals (1). While we found promising evidence from 21 studies that there are significant benefits, a gap in reporting clinician or care team satisfaction as a PCMH metric persists. Clinical, financial and quality metrics are undoubtedly important, but without understanding the impact of these transformations on those delivering the care, we still have many questions. In 2010, Reid and colleagues reported improvement in patient experience, quality of care and clinician burnout through 2 years in the medical home pilot site of Group Health Cooperative compared to control sites (2). This was the first glimpse into the clinician piece of the large puzzle, and left us desiring more evidence in this area. Earlier this year, my colleagues in the Center for Excellence in Primary Care reported that tight team structure and collaborative team culture were associated with less clinician and staff exhaustion on the Maslach emotional exhaustion scale (3). These findings provided more insight into how certain practice transformations (i.e. team-based care) under the PCMH.
In this current issue of the Annals of Family Medicine, Alidina and colleagues offer more hope for practices and organizations undergoing practice transformation efforts, through clinician and staff surveys on organizational culture, office chaos, and difficulties providing safe and high quality care in two state medical home pilot projects. The four outcome measures they assessed were job satisfaction, stress, burnout and intention to leave. The authors build upon what has been previously reported about organizational culture and introduce office chaos more intentionally into the PCMH measurement milieu, but it will be helpful to pull the thread more in this area. Are the effects of natural chaos induced by practice change and disruption time-limited or persistent even after change has been transformed to culture? While we expect a certain element of office chaos as practices transform, how can we more ably predict, prepare for and mitigate it? Chaos is multifactorial and complicated, but contributors to chaos should be further explored. How much of an impact does the adoption of electronic medical records play? A 2012 Family Practice Management E.H.R. survey found that 15% of respondents had changed E.H.Rs at least once due to dissatisfaction, and another study found that 31% of 17,000 E.H.R users would like to change vendors (4). A 2013 RAND study also found that E.H.R satisfaction is an independent predictor of professional satisfaction, and gross physician discontent with poor E.H.R usability, time consumption and degradation of the care interface (5). Are we underestimating the impact of E.H.R adoption and implementation in practices? Is this phenomenon contributing to chaos and burnout, to what extent, and will it persist?
The findings in this study are instructive for those transforming practices or coaching practices as they transform, but future studies will need to dive deeper into strategies that successfully focus on providing high quality care, and skills to manage and shorten the effect of chaos. Future studies focusing on the additional aim of clinician satisfaction (3), the missing metric, including measures that capture totality of the experiences of the care team and the impact of various components of transformation, are essential.
References
1. Nielsen M, Olayiwola JN, Grundy P, Grumbach K. The patient-centered medical home's impact on cost and quality: an annual update of the evidence, 2012-2013. Patient-Centered Primary Care Collaborative. 2014.
2. Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Affairs. 2010 May;29(5):835-43.
3. Willard-Grace R, Hessler D, Rogers E, Dube K, Bodenheimer T, Grumbach K. Team structure and culture are associated with lower burnout in primary care. J Am Board Fam Med. 2014;27(2):229-38.
4. Edsall RL, Adler KG. The 2012 EHR user satisfaction survey: responses from 3,088 family physicians. Fam Pract Manag. 2012;19(6):23-30.
5. Freidberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, Calif: RAND Corporation; 2013.
Competing interests: None declared
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Competing Interests: None declared.