The Teamlet Model of Primary Care

The teamlet model Bodenheimer describes already exists and is rapidly evolving in multiple family medicine practices of many types across the nation: small private practices, large groups, Community Health Centers, and academic. It is being driven by the palpable change in efficiency, quality, and satisfaction for patients, staff and providers who experience it.

We have developed a similar model in the University of Utah Community Clinics, an 11-site, 100-provider multidisciplinary practice network caring for over 125,000 active patients. We have tested the model in our smaller practices and are now implementing it over time in all our sites. Along the way, we have learned some lessons that add to Bodenheimer’s excellent description of the model:

• It is useful to think of the role of the health coach (in our case, a medical assistant (MA) with advanced training) as delivering the visit to the patient. An MA greets a patient on arrival (no receptionist, no waiting), verifies identifying and insurance information, and takes the patient to an examination room where the MA immediately begins the clinical visit (a similar model is described in Gordon P, Chin M. Achieving a New Standard in Primary Care for Low-Income Populations: Case Study 1: Redesigning the Patient Visit, The Commonwealth Fund, August 2004, http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=235281#areaCitation, accessed November 3, 2007). Delivering the visit to the patient in the room and never abandoning the patient dramatically reduces patient cycle time in the office (Endsley S, Magill MK, Godfrey MM. Creating a Lean Practice. Fam Pract Mgmt April 2006: 34-8).

• Advanced training for MAs can go farther than we might have imagined. In our case, MAs register patients, scribe histories and physical examinations using an extensive library of computer-based templates, draw blood, take xrays under a limited radiology technician license, explain computerized after visit summaries.to patients, schedule follow-up appointments, and maintain contact with patients such as those due for chronic disease management or health maintenance. This is consistent with the pattern of “up-migration” of disciplines over time described by Christensen. (Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations save health care? Harvard Business Review Sep-Oct 2000: 20-8.)

• With an adequate supply of MAs, the practice maintains the same staff to physician ratio and overhead as do traditional model practices, with MAs replacing staff who had served other, more limited roles. Ideally, the teamlet-based practice has 5 MAs to 2 physicians, eliminating need for receptionists, phlebotomists, and medical records personnel. In our setting, this is further supported by an off-site call center and robust electronic health record (EHR). It’s amazing how helpful it is for the telephone not to ring while the teamlet cares for patients. Response time to patient calls for clinical issues is actually reduced, as messages flow efficiently through the EHR messaging function.

• With an adequate ratio of MAs to providers, physician time with patients flows smoothly. The physician is no longer the bottleneck for the practice. But neither is the MA. When a relatively complicated, talkative, or distressed patient arrives, a single MA can devote as much time to the patient as needed, while the other MAs and providers maintain flow of patients through the practice. When the more complex patient is prepared to see the provider, the actual provider time required is not much different from that for other patients. One of our physicians describes this as analogous to a railroad siding. The MA and the patient needing extra time spend as much time as needed on the siding, while the main line traffic continues to flow. Once ready, the patient from the siding re-enters the mainline without interruption.

• Training and retention of health coaches is a rate limiting step for implementation of the teamlet. In our area, no training program provides MAs with all the skills. We have therefore developed our own training program. Small practices may be vulnerable to turnover of the health coaches: absence or loss of just one or two causes breakdown of the model. Large groups such as ours may offer flexible coverage, but at the price of more difficulty standardizing provider and MA roles across teams.

Competing interests:   None declared