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

Christine A. Sinsky; Thomas Bodenheimer

doi:10.1370/afm.2422

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Table 1

Old vs New Mindsets

Old Mindsets	New Mindsets
The doctor does it all.	Share the care with the team: there is too much work to be done by 1 person, and it is too important to be left to chance.
The nonclinician team members have minimal skills and make limited contributions; so few are needed.	A well-trained and mentored team of at least 2 clinical assistants (MAs or nurses) per clinician is needed to fully leverage the skills of all. Care is better and more satisfying if work is strategically delegated according to ability.
Technology replaces people, therefore fewer people are needed.	People provide health care; technology plays a supporting role.
Health care is a transactional endeavor, the sum of many discrete tasks: in this model anybody will do.	Health care is a relational endeavor, founded on trusting and healing relationships. Continuity with the same people matters.
Regulatory over-reach: what you want to do is not allowed.	If what you want to do is safe and helps patients, do it. If each team member is trained, mentored, and audited for a certain task within the bounds of governmental regulation, health systems should allow it.
Overhead cost accounting: margins are tight, so we need to trim staff. Clinicians will have to pick up the slack and do work that the support staff might have done. If physicians leave the organization, we will hire more physicians and/or less costly clinicians.	Opportunity cost accounting: by way of a simple hypothetical example, with a staffing ratio of 1:1 (CTC: MD) the primary care team may have the capacity to see patients that generate 6 RVUs per hour. With a staffing ratio of 3:1 the team will provide more patient visits that are more comprehensive and may generate 9 RVUs per hour. The difference is the opportunity cost: the organization lost the opportunity to generate 3 more RVUs per hour.

CTC = care team coordinator; MA = medical assistant; MD = doctor of medicine; RVU = relative value unit.

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The Article in Brief

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

Thomas Bodenheimer , and colleagues

Background Primary care teams are underpowered because they do not maximally redistribute team functions, causing physicians to perform time-consuming clerical work. This commentary describes "advanced team care with in-room support" as a way to power-up primary care teams.

What This Study Found In this special report, the authors argue that the current primary care team paradigm is underpowered, in that most of the administrative responsibility still falls mainly on the physician. Jobs not requiring a medical education, such as entering data into electronic health records, should not be handled by physicians and advanced practitioners. The authors propose a model where a physician with 2 or 3 highly trained care team coordinators (CTCs) share patient responsibilities, with the CTCs organizing the visit, completing documentation, and coordinating follow-up care, and the physician handling components of the visit that require more complex decision making. There is evidence that this model improves patient care, reduces physician burnout, and is financially sustainable.

Implications

The authors identify a number of themes, or mindsets, such as the idea that technology can replace people, that are barriers to implementation of these models in family medicine.