Improving Practice Efficiency Through Team-based Care

It is well established that practice inefficiency is one of the key drivers of healthcare provider well-being.¹ How can we decrease the administrative burden of care, while also allowing for deeper connection with patients?

Team-based care allows each member of the healthcare team to function at the top of his or her license, thereby improving efficiency of patient care and ultimately the well-being and engagement of all members of the team.  

•    A strategic redistribution of work among members of a practice team
•    Right person doing the right work at the right time

Several aspects of team-based care and documentation that may be worth considering for your practice are reviewed here.   

Why Team-based Care?
In team-based care, a team led by the physician or advanced practice provider provides the various elements of a visit’s care together, each practicing at the full extent of their training. This model engages a greater number of staff and allows the provider the time to listen to patients, carefully consider differential diagnoses and treatment plans, and cultivate meaningful relationships with patients. Also, it provides team members the knowledge and background of patients’ histories and treatment plans, thereby better equipping them to respond to patient questions and requests between visits. Ultimately, all members of the team feel more engaged in their important role of caring for the patient.

Components of Team-based Care
Pre-visit planning
Obtaining outside medical records or test results before the visit can improve the efficiency of the visit. Also automated pre-appointment reminders can remind patients to arrive early to complete pre-visit questionnaires. Some of that information completed by patients may then be directly imported into the medical record.  

Pre-visit laboratory testing
At the end of each appointment, the provider can order pre-visit labs for the next visit. Then, at the next visit, the provider can review the lab results in person with the patient and discuss interpretation and next steps. This eliminates the need for follow-up phone calls or messages, and ultimately can be a great time-saver.

Team huddle
A five-minute team huddle at the beginning of the day can shift the model from being “reactive” (always playing catch-up) to “proactive” (anticipating and coordinating needs in advance). Include all members of the care team, including registration or check-in staff, nurses, medical assistants (MAs), physicians, and advanced practice providers. The huddle can allow for planning of who will cover for any call-outs, anticipate busier times of days, and foster cohesion in approaching the day’s activities.  

Team-based Visit
“Expanded rooming”
During “expanded rooming,” the nurse or MA is empowered to enter certain elements of the medical record, such as History of Present Illness (HPI), the Review of Systems (ROS) and Past, Family, and/or Social History (PFSH), as well as any part of the chief complaint (CC) or history for new and established office/outpatient E/M visits. Of note, the billing practitioner provider must review the information and note in the medical record that she or he has supplemented and/or confirmed the information recorded by others.^2-4

The nurse or MA can also reconcile medications, identify the purpose of the visit, and then hand-off the visit to the provider by summarizing the patient’s visit objective and any other pertinent information.

“Team documentation”
Once the provider enters the room, the nurse, MA or documentation specialist documents the visit while the provider obtains additional history and develops the treatment plan with the patient. The nurse or MA also prepares the after-visit summary during this time.

“Expanded discharge”
During “expanded discharge,” the nurse or MA provides patient education and health coaching, reviews the plan of care (including printing and reviewing the visit summary), and conducts follow-up care coordination, such as the ordering and scheduling of labs or studies.  

Provider exits room and reviews, modifies and signs note
Team-based care allows the provider to fully complete documentation from one patient visit before moving on to another, thereby minimizing “work after work.”

Co-location of team members
Finally, having team members sit in close proximity to one another can allow for more frequent and productive communication. Patient questions and requests that come in throughout the day (for example via shared inboxes) can be quickly triaged, rather than waiting for the end of the day.

In summary, the various aspects of team-based care may help to ease the administrative burden on providers and enhance the engagement of team members, while also improving the patient’s experience. For more information on how to implement some of these approaches in your practice, the American Medical Association’s STEPS Forward Program has an online module on “Implementing Team-Based Care”.

References:
1.    Wright et al. N Engl J Med 2018; 378:309-311.
2.    Bodenheimer T., Bauer L., Olayiwola J.N. (2015). RN Role Reimagined: How Empowering Registered Nurses Can Improve Primary Care. Retrieved from http://www.chcf.org/publications/2015/08/rn-role-reimagined.
3.    Centers for Medicare & Medicaid Services. (2012). Stage 2 Eligible Professional Meaningful Use Core Measures: Measure 1 of 17. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_1_CPOE_MedicationOrders.pdf.
4.    Centers for Medicare & Medicaid Services. (2018). Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQs) Physician Fee Schedule (PFS). Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-M-Visit-FAQs-PFS.pdf.