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DiscussionSpecial Reports

Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support

Christine A. Sinsky and Thomas Bodenheimer
The Annals of Family Medicine July 2019, 17 (4) 367-371; DOI: https://doi.org/10.1370/afm.2422
Christine A. Sinsky
1American Medical Association, Chicago, Illinois
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Thomas Bodenheimer
2University of California, San Francisco, San Francisco, California
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  • For correspondence: Tombodie3@gmail.com
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  • Thank you, but . . .
    Robert S. Watkins
    Published on: 14 August 2019
  • Team Documentation In-Room Support Re: Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support
    Megan R. Mahoney, MD
    Published on: 31 July 2019
  • Published on: (14 August 2019)
    Page navigation anchor for Thank you, but . . .
    Thank you, but . . .
    • Robert S. Watkins, Private Practice Family Physician

    The financial sustainability of the practice model described here is entirely dependent on revenue/office visit - i.e., negotiated fee schedules with private insurers, applicability of facility fees, percentage of Medicare/Medicaid patients, amount of indigent care, etc. Physicians in solo, small, rural or inner city practices, already just getting by on razor thin margins, cannot churn patients through fast enough to c...

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    The financial sustainability of the practice model described here is entirely dependent on revenue/office visit - i.e., negotiated fee schedules with private insurers, applicability of facility fees, percentage of Medicare/Medicaid patients, amount of indigent care, etc. Physicians in solo, small, rural or inner city practices, already just getting by on razor thin margins, cannot churn patients through fast enough to cover the increased overhead proposed here. This plan would put them out of business.

    In his recent interview with AAFP News, Dr. Bodenheimer correctly identifies the stressors that are killing primary care in this country: "large patient panels, frustrating EHRs and exhausting administrative work." Sadly, what is proposed here is not solutions to those problems, but, at best, coping mechanisms and work-arounds.

    I went back and read the authors' 2017 article on moving towards the Quadruple Aim. It is deeply discouraging how much the work environment for most primary care physicians has deteriorated in just two years. Let's stop trying to find tricks that make a completely broken system a little less intolerable, and forcefully and aggressively attack the root problems. If we don't, it will very soon be too late.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (31 July 2019)
    Page navigation anchor for Team Documentation In-Room Support Re: Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support
    Team Documentation In-Room Support Re: Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support
    • Megan R. Mahoney, MD, Clinical Professor
    • Other Contributors:

    We commend Sinsky and Bodenheimer for their article in the July/August 2019 issue of Annals of Family Medicine on powering up the primary care team with in-room support to "maximally redistribute team functions."(p367) We agree that "The higher the skill level of the CTC [care team coordinator], the more responsibilities are shared. Ideally, an extended care team of additional colocated health professionals, such...

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    We commend Sinsky and Bodenheimer for their article in the July/August 2019 issue of Annals of Family Medicine on powering up the primary care team with in-room support to "maximally redistribute team functions."(p367) We agree that "The higher the skill level of the CTC [care team coordinator], the more responsibilities are shared. Ideally, an extended care team of additional colocated health professionals, such as a pharmacist, social worker, and behaviorist, support several core teams." (p367) In 2015, Stanford Primary Care initiated a broad-based practice redesign effort to empower the primary care team, called Stanford Primary Care 2.0, including the extended care team as described.(1) Specifically, CTCs in Stanford Primary Care 2.0 have responsibilities that include expanded rooming tasks, in-room documentation, health coaching, previsit planning, and in-basket management.(2)

    Sinsky and Bodenheimer emphasize the benefits of CTCs in-room support that extend beyond documentation: "CTCs are far more than scribes; they are true clinical partners."(p369). Early interviews with Stanford Primary Care 2.0 CTCs highlight the increased sense of empowerment within the primary care team: "I love being able to have more control. I feel more respected in this position because they trust me to do all these extra things."(2) .

    During the 3 years of Stanford Primary Care 2.0 implementation, we encountered many advantages and disadvantages associated with the CTC providing in-room documentation support that were elucidated during interviews with eight providers and nine CTCs.(3) The main advantage was the ability of providers to give better and more efficient patient care. Primary Care 2.0 CTCs and providers discussed how CTCs contributed to the patient experience by serving as an extra set of ears for the provider, and surveyor of the patients' needs. The CTCs were experienced medical assistants, and patients trusted their guidance. CTCs answered patient questions during and post visit, and provided individualized guidance while appropriately deferring medical questions to providers. Primary Care 2.0 providers alluded to CTCs catching near misses related to intended prescriptions and referrals through diligent note-taking and close collaborative CTC/provider debriefing post visit.

    Major disadvantages were associated with the need for initial and ongoing training. CTCs needed to learn to capture key information and provide quality documentation, and clinics needed to invest CTC time and practice and dedicate provider time to give feedback and direction to CTCs. Providers reported that the notes did not always meet their expectations due to missing information and superfluous details. Some providers voiced frustration at having to correct CTCs' notes due to errors or missing data; provider's documentation preferences varied, as did consistent availability of CTCs, given their many competing roles. For some, it was not clear that CTCs providing documentation support consistently reduced workload.

    Interestingly, clinics did not report patients refusing to have a CTC in the room as a barrier, as refusals happened infrequently.

    We thank the authors for articulating the vision for the primary care team model and early findings. We share their enthusiasm for shifting the mindset to teams, relationships, and connection in primary care.

    Competing interests: None declared

    1. Brown-Johnson, C. G., Chan, G. K., Winget, M., Shaw, J. G., Patton, K., Hussain, R., Olayiwola, J. N., Chang, S., Mahoney, M. Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim. Am J Med Qual. 2019 Jul/Aug;34(4):339-347

    2. Levine, M. L. Transforming Medical Assistant to Care Coordinator to Achieve the Quadruple Aim. Society of General Internal Medicine Forum. 2018; V4(4)

    3. Brown-Johnson, C. G., Levine, M. L., Mahoney M. R. Tale of Two Scribes. Presented at: Society of General Internal Medicine Annual Meeting April 19-22, 2017. Accessed July 29, 2019

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 17 (4)
The Annals of Family Medicine: 17 (4)
Vol. 17, Issue 4
July/August 2019
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Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support
Christine A. Sinsky, Thomas Bodenheimer
The Annals of Family Medicine Jul 2019, 17 (4) 367-371; DOI: 10.1370/afm.2422

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Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support
Christine A. Sinsky, Thomas Bodenheimer
The Annals of Family Medicine Jul 2019, 17 (4) 367-371; DOI: 10.1370/afm.2422
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    • ADVANCED TEAM CARE WITH IN-ROOM SUPPORT
    • EVIDENCE TO SUPPORT THIS MODEL
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