What is the challenge?
Primary care practices are experiencing a high demand for services, due in part to the historic expansion of health care coverage under the Affordable Care Act. It is clear that teams can and do play an integral role in expanding access to care by extending provider capacity and ensuring that evidence-based preventive and chronic care needs are met, even as the complexity and number of patients seeking care grows. Improving both care and access requires that primary care practices think in new ways about where and when patients access primary care, and who they see.
What needs to change?
Primary care practices have historically been organized by face-to-face encounters between a provider and a patient during regular weekday hours. As demand for primary care has grown, providers today often find themselves on a “hamster wheel” running from visit to visit without time to meaningfully engage with patients in a proactive or planned way. New models for providing access to care are needed. These models may entail using care team members, like registered nurses, behaviorists, or pharmacists more creatively. Patients may also be seen in groups rather than one-on-one, or through virtual or phone encounters rather than in person. Innovations in payment will have to accompany any innovations in care delivery. High quality data will be needed to ensure patients receive the care they need. Patient feedback will be essential to ensure continuity of care between the patient and his or her care team is not disrupted.
What do we gain by making these changes?
Ensuring access to high quality, team-based care is one of the most effective interventions for improving the health of people with chronic illness. It also results in improvements in patient experience and reduction in health care costs. Meeting patient needs for care by substituting encounters with other members of the practice team, or encounters other than one-on-one office visits, can increase access while reducing provider appointment demand.
Understand the population of patients for whom the primary care team is responsible.
A practice clearly cares for the patients who come in for a visit. But there are other people the practice must care for too. Patients who have not come in recently may need proactive care. Managed care organizations may assign patients with new insurance to a practice. New patients from the community may call for advice or walk in for urgent care. Practices must have the capacity to clearly define and understand their whole population of patients, and develop and maintain up-to-date rosters of patients for each care team.
Use the full care team to best meet patient care needs.
Patients can get some of their health needs met by a variety of care team members other than providers, including behaviorists, nurses, medical assistants, and even lay care guides or community health workers. Depending on funding and reimbursement, these staff can provide needed services either in their own independent visits, as part of comprehensive visits, or in the home or community setting. By having other team members participate in preventive care, routine chronic disease follow-up, self-management counseling, or chart documentation, providers should have more time for patient care.
Create alternatives to one-on-one, face-to-face visits.
With supportive payment, practices can care for patients more effectively and efficiently outside of the one-on-one provider visit. Patients can get access to answers and information via telephone or email without having to make a trip to the primary care office. They can receive support from peers in a group setting. Each of these strategies, while effective, creates new demands on the practice team, so must be considered carefully.
Develop, measure, and improve access services for new patients.
In this time of rapid expansion of health care insurance, special attention must be paid to the care of new patients. These patients may not have accessed care for some time and will require extra time to develop a trusting, longitudinal relationship with the primary care team. They will also benefit from an orientation to the practice, and how best to access care.
Embed what works by clearly defining care team roles.
Experimenting with new ways of providing access to care for patients in the primary care practice, in their homes, and in the community is exciting. Once you find techniques and arrangements that work based on your patients' needs and your clinical capacity, spend time formalizing and embedding those systems.