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

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