A Nurse a Day Keeps the Doctor Away

A Nurse a Day Keeps the Doctor Away

Rethinking health care teams

 The clinics at the forefront of implementing the Alternative Payment Methodology (APM) are very excited to think more about new ways of providing care to their patient populations. Under APM, clinics receive a capitated per-member per-month rate, thus shifting the financial incentive from office visits with a physician towards providing team-based care. According to the Oregon Primary Care Association (OPCA), the APM model “removes old bottle necks,” and enables community health centers (CHCs) to transition from “the provider centric model of care delivery to a more advanced, team-based model.” The hope is this payment model will enable patient-centered primary care homes (PCPCH) to address a wider range of health factors.

These organizations on the frontlines of rethinking primary care have an opportunity to revisit some basic questions: What’s the ideal patient panel size?  Who manages the patient panel? And more generally, what does the care team look like?

Physicians as medical care specialists

The role of the physician is evolving during the transition to PCPCH. While it may seem counter-intuitive, medical staff point out that the medical component of a typical clinic visit is only a small piece of the time they spend at the clinic, and many patients do not need to see a medical person at all. It is in this light that the medical care provided by the physician can become a highly trained specialty within the overall health care team.

Laurie Francis, a Senior Director of Clinic Operations and Quality with the Oregon Primary Care Association (OPCA), explains that many patient needs can be addressed by other members of the care team and don’t require the expertise of a physician.  “When I’ve talked to family practitioners and the internal medicine doctors who are doing this work, they estimate that maybe about fifteen to twenty percent of their day is actually needed for a medical visit.  This means for eighty percent of the day, most of the patients don’t need to see a medical person. They need social support, economic support, psychological; all the things that we know cause people to be chronically ill for a long period of time.”

Increasing role of the care team

Who fills in the rest of that eighty percent? Clinics are talking about larger roles for medical assistants, nurse care managers, health coaches, community health workers, case managers, and behavioral health specialists. These medical team members can often be better than physicians at communicating, listening, and reflecting on what patients are struggling with, because they have time specifically dedicated to this purpose.

In a previous post, we discussed the importance of social determinants to health care delivery and noted that a person’s social context can complicate their medical care. Clinical staff (rather than physicians) can address those factors while the patient is in clinic, thereby improving health outcomes. Not only do they often have more capacity than physicians, but they also have a skill set suited to this work. For example, health coaches and behavioral health specialists are trained and skilled in helping people make lifestyle changes. Community health workers can connect people with non-medical community resources. Linking patients to behavioral, psychosocial and economic support (enabling services) can help improve health outcomes for people with complicating situations (such as food insufficiency, poverty, or cultural barriers).

Moreover, these staff members are really good at cohort management, which is a fancy way of saying managing groups of people with a shared chronic disease like hypertension or diabetes. In contrast to the approach of yesterday, with thousands of patients managed by a single physician, some organizations are experimenting with creating small panels of highly similar patients, for example those with Hepatitis C and co-occurring disorders, who can be managed by a nurse or other designated member of the care team.

“[The physicians] still have a relationship with people, which is really important …But they’re using their skills and working at the top of their license,” explains Laurie.

Looking forward, care teams may look radically different than the teams found in most of today’s US healthcare settings. Instead of relying solely on physicians to provide the range of services that patients need, the new model will draw on the varied skills of the entire health care team, thus enabling physicians to focus on delivering the medical care they are uniquely qualified to provide.

In future posts, we will explore the challenges of staffing this new model and how professional organizations are providing new training resources to achieve the potential of team-based care.