Three Models of Primary Care Teaming TL CC and ET An Unexplored Feature of the Medical Home

What defines optimal outpatient primary care "teaming?"

The Disease Management Care Blog just assumed that if it took equal scoops of adaptable physicians, dedicated nurses and supportive culture and baked with a dollop of accountability, "teaming" would just.... happen.

It turns out that what may come out of that clinical practice oven is a lot more complicated than that. 

Which is why medical home advocates should pay attention to this article by George Washington Universitys Debra Goetz Goldberg and colleagues.  Interested in finding out more about primary care "teaming," they interviewed, reviewed and observed three different Virginia clinics that had embarked on transformative quality improvement programs.

Each clinic came up with a different version of "teaming":

1."Top of License" - nurses interviewed the patients, presented the problems to the docs and then documented the care plan.  They were also responsible for the patient education.  Thanks to using this model, the physicians almost doubled the number of patients they were seeing per day.

2. "Care Coordinator" - nurses focused on helping patients undergoing care "transitions" (typically out of the hospital) and provided self-management and health education to high-risk, high complexity patients.  Interestingly, unsatisfactory reimbursement levels forced the practice to cut back, but they still doubled mammography and blood pressure control rates among persons with diabetes mellitus.

3. "Enhanced Traditional" - the physicians still performed the bulk of the patient care but the researchers observed that the other clinic personnel benefited from increased trust, communication and hand-offs that translated into patient centered care, shared responsibility and heightened volunteerism.  The practice was unable to measure any outcomes.

"Very interesting!" says the DMCB. Authoritative web-sites like this or this and peer-reviewed articles like this er to "teaming," but fail to precisely define it.  Assuming the three categories described by Goetz-Goldberg (in shorthand, "TL," "CC" and "ET") hold up in future studies, the DMCB looks forward to learning which approach results in the greatest quality or cost-savings.

Coda: As a reader bonus, the authors offer up a definition of "team-based care" that seems to span all three models and can be used for the DMCB readers quoting pleasure:

"A group of diverse clinicians who participate in and communicate with each other regularly about the care of a defined group or panel of patients."

New study suggests using sedentary behavior counseling in primary care

Although primary care physicians take care of many aspects of health and disease, little is known about how they can change sedentary behavior through counseling, according to researchers at The University of Texas Health Science Center at Houston (UTHealth). Results from a new study suggest encouraging patients to decrease the time they spend sitting each day may be feasible in the primary care setting.

“Reducing sedentary time can be done by virtually everyone and requires smaller changes in energy expenditure than meeting physical activity guidelines, which usually entails a complex behavior change particularly for inactive patients,” said Kerem Shuval, Ph.D., principal investigator and assistant professor of epidemiology at The University of Texas School of Public Health Dallas Regional Campus, part of UTHealth. “Reducing sedentary time helps promote health and primary care physicians can play a major role in modifying their patients’ sedentary behavior, particularly because adults spend many of their waking hours each day sitting or in passive leisure activities.”

Results were recently published online in the British Journal of Sports Medicine.

Unlike physical activity counseling, which has been investigated over the years, sedentary behavior counseling is a new term used in this study to describe a dialogue with a patient about the harmful effects of prolonged uninterrupted sitting. The average amount of time spent sitting or reclining during waking hours in the United States is almost 8hours per day, according to data from the National Health and Nutrition Examination Survey.

In this study, Shuval and his colleagues asked adult primary care patients whether their providers asked, advised and encouraged them to modify their physical activity and sedentary behavior in the past year. The “5A” (ask, advise, agree, assist and arrange) framework was used to examine these questions.

Study results indicated that within the last year, only 10 percent of patients received sedentary behavior counseling compared to 53 percent who received physical activity counseling. No patients received a plan pertaining to decreasing sedentary behavior; however, 14 percent were provided with a written plan for increasing physical activity. More social support and specific strategies for behavior change were provided as it relates to increasing physical activity than decreasing sedentary behavior. Obese patients were more likely to receive counseling to decrease their sitting time.

“Accumulating evidence has found prolonged sitting to be associated with increased risk for chronic diseases such as obesity and type 2 diabetes as well as premature death,” said Shuval, who is also an adjunct professor at The University of Texas Southwestern Medical Center (UT Southwestern) and a member of the Harold C. Simmons Cancer Center at UT Southwestern.

Sedentary behavior has emerged as a new field of scientific investigation due to the detrimental health effects of prolonged sitting, according to Shuval. A number of studies have begun to explore the impact of interventions specifically focused on reducing and breaking up sedentary time.

“Our study provides initial insight into sedentary behavior counseling practices in the primary care setting,” said Shuval. “Additional research is needed prior to developing programs to change patients’ sedentary behavior.” Several countries have already begun to provide general recommendations to decrease sedentary time.