From the Practice of the Past From the Practice of the Past to the Practice of the Futureto the Practice of the Future

April 26, 2010April 26, 2010

Thomas Bodenheimer MDThomas Bodenheimer MDDepartment of Family and Community MedicineDepartment of Family and Community Medicine

University of California, San FranciscoUniversity of California, San Francisco

ObjectivesObjectives

• To review the current crisis in To review the current crisis in primary careprimary care

• To describe the features of a primary To describe the features of a primary care practice of the future (“Patient-care practice of the future (“Patient-Centered Medical Home”)Centered Medical Home”)

• To explore why interprofessional To explore why interprofessional education is needed to bring the education is needed to bring the practice of the future into realitypractice of the future into reality

Lone doctor modelLone doctor model

• The current primary and specialty care model The current primary and specialty care model is a lone doctor modelis a lone doctor model

• The doctor is responsible for everythingThe doctor is responsible for everything• The doctor doles out tasks to other team The doctor doles out tasks to other team

members but they do not share responsibility members but they do not share responsibility or pride for patient outcomesor pride for patient outcomes

• Many patients view the doctor as the only Many patients view the doctor as the only person who can solve their problemsperson who can solve their problems

The lone doctor model is in crisis in The lone doctor model is in crisis in adult primary careadult primary care

• 2007 survey of fourth-year students, 7% planned 2007 survey of fourth-year students, 7% planned adult primary careadult primary care careers careers [Hauer et al, JAMA 2008;300:1154].[Hauer et al, JAMA 2008;300:1154].

• American College of Physicians (2006): “primary American College of Physicians (2006): “primary care, the backbone of the nation’s health care care, the backbone of the nation’s health care system, is at grave risk of collapse.”system, is at grave risk of collapse.”

• Reasons for lack of interest in primary care careersReasons for lack of interest in primary care careers– PCPs earn on average 54% of what specialists PCPs earn on average 54% of what specialists

earn and most medical students graduate with earn and most medical students graduate with >$120,000 in debt>$120,000 in debt

– More importantly, worklife of the PCP is stressful More importantly, worklife of the PCP is stressful

Stressful worklifeStressful worklife

• Survey of 422 general internists and Survey of 422 general internists and family physicians 2001-2005family physicians 2001-2005– 48%: work pace is chaotic48%: work pace is chaotic– 78%: little control over the work78%: little control over the work– 27%: definitely burning out27%: definitely burning out– 30%: likely to leave the practice 30%: likely to leave the practice

within 2 yearswithin 2 years

Linzer et al. Annals of Internal Medicine 2009;151:28-36Linzer et al. Annals of Internal Medicine 2009;151:28-36

““Across the globe Across the globe doctors are miserable doctors are miserable because they feel like because they feel like hamsters on a hamsters on a treadmill. They must treadmill. They must run faster just to stay run faster just to stay still.”still.”

Morrison and Smith, Morrison and Smith, BMJ, 2001BMJ, 2001

PCP Burn OutPCP Burn Out

Colwill et al., Health Affairs, Colwill et al., Health Affairs,

2008:w232-2412008:w232-241

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2000 2005 2010 2015 2020

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Adult Care: Projected Generalist Supply Adult Care: Projected Generalist Supply vs Pop Growth+Agingvs Pop Growth+Aging

Demand:adult pop’nDemand:adult pop’ngrowth/aginggrowth/aging

Supply, Family Supply, Family Med, Gen’l Med, Gen’l Internal MedInternal Med

Not enough NP/PAs Not enough NP/PAs to close the gapto close the gap

Lone doctor model effect on patientsLone doctor model effect on patients

• Access: 73% of adults surveyed reported Access: 73% of adults surveyed reported difficulty getting a prompt appointment, difficulty getting a prompt appointment, getting phone advice, or getting care getting phone advice, or getting care nights/weekends without going to the ED nights/weekends without going to the ED

• Care coordination: Specialists in one Care coordination: Specialists in one study reported they received no study reported they received no information from PCP in 68% of referralsinformation from PCP in 68% of referrals

Public views on of US health system organization, Public views on of US health system organization, Commonwealth Fund, 2008. Gandhi et al. J Gen Internal Commonwealth Fund, 2008. Gandhi et al. J Gen Internal Med 2000;15:626. Commonwealth Fund, National Med 2000;15:626. Commonwealth Fund, National Scorecard, 2008.Scorecard, 2008.

Effect on patientsEffect on patients

• A study of 264 visits to primary care A study of 264 visits to primary care physicians using audiotapesphysicians using audiotapes

• Patients making an initial statement of Patients making an initial statement of their problem were interrupted by the their problem were interrupted by the physician after an average of 23 secondsphysician after an average of 23 seconds

• In 25% of visits the physician never asked In 25% of visits the physician never asked the patient for his/her concerns at all the patient for his/her concerns at all [Marvel [Marvel et al. JAMA 1999;281:283et al. JAMA 1999;281:283]

Effect on patientsEffect on patients

• Despite well-designed guidelines for hypertension, Despite well-designed guidelines for hypertension, hyperlipemia, and diabeteshyperlipemia, and diabetes

• Despite widespread guideline dissemination to Despite widespread guideline dissemination to physicians for yearsphysicians for years

– 65% of people with HBP are poorly controlled 65% of people with HBP are poorly controlled – 62% with elevated LDL have not reached lipid-62% with elevated LDL have not reached lipid-

lowering goalslowering goals– 63% of people with diabetes have HbA1c > 763% of people with diabetes have HbA1c > 7

Roumie et al. Ann Intern Med 2006;145:165, Afonso et al. Am J Manag Roumie et al. Ann Intern Med 2006;145:165, Afonso et al. Am J Manag Care 2006;12:589, Saydah et al. JAMA 2004;291:335.Care 2006;12:589, Saydah et al. JAMA 2004;291:335.

Effect on patientsEffect on patients

• Asking patients to repeat back what the physician Asking patients to repeat back what the physician told them, half get it wrong.told them, half get it wrong. [Schillinger et al. Arch Intern Med [Schillinger et al. Arch Intern Med 2003;163:83]2003;163:83]

• Asking patients: “Describe how you take this Asking patients: “Describe how you take this medication” -- 50% don’t understand and take it medication” -- 50% don’t understand and take it differently than prescribeddifferently than prescribed [Schillinger et al. Medication[Schillinger et al. Medication miscommunicationmiscommunication, in Advances in Patient Safety (AHRQ, 2005)], in Advances in Patient Safety (AHRQ, 2005)]

• 50% of patients leave the physician office visit 50% of patients leave the physician office visit without understanding what the physician saidwithout understanding what the physician said [Roter and Hall. Ann Rev Public Health 1989;10:163][Roter and Hall. Ann Rev Public Health 1989;10:163]

Effect on patientsEffect on patients

• Patients more actively involved in their care had Patients more actively involved in their care had better HbA1c levels than those less involvedbetter HbA1c levels than those less involved

[Heisler et al. Diabetes Care 2003;26:738][Heisler et al. Diabetes Care 2003;26:738]

• More patient participation in the medical visit, More patient participation in the medical visit, more likely to take medications correctlymore likely to take medications correctly [O’Brien [O’Brien et al. Medical Care Review 1992;49:435]et al. Medical Care Review 1992;49:435]

• In a study of 1000 physician visits, the patient did In a study of 1000 physician visits, the patient did not participate in decisions 91% of the timenot participate in decisions 91% of the time

[Braddock et al. JAMA 1999;282;2313][Braddock et al. JAMA 1999;282;2313]

With current panel sizes,With current panel sizes,lone doctor model is ridiculouslone doctor model is ridiculous

• Average panel size for many practices Average panel size for many practices 23002300

• A primary care physician with an panel of 2500 A primary care physician with an panel of 2500 average patients will spend 7.4 hours per day average patients will spend 7.4 hours per day doing recommended doing recommended preventive carepreventive care [Yarnall et al. [Yarnall et al. Am J Public Health 2003;93:635]Am J Public Health 2003;93:635]

• A primary care physician with an panel of 2500 A primary care physician with an panel of 2500 average patients will spend 10.6 hours per day average patients will spend 10.6 hours per day doing recommended doing recommended chronic carechronic care [Ostbye et al. Annals [Ostbye et al. Annals of Fam Med 2005;3:209]of Fam Med 2005;3:209]

In adult primary care In adult primary care the lone doctor model isn’t workingthe lone doctor model isn’t working

• Plummeting numbers of Plummeting numbers of new physicians entering new physicians entering primary careprimary care

• Declining access to Declining access to primary careprimary care

• Physician burn-outPhysician burn-out• Unsatisfactory quality Unsatisfactory quality • The primary care The primary care

medical home is falling medical home is falling off the cliffoff the cliff

Patient-Centered Medical Home Patient-Centered Medical Home (PCMH)(PCMH)

•AAP: pediatric practices AAP: pediatric practices for children with special for children with special needs (1967) - medical needs (1967) - medical homehome•AAFP: Future of Family AAFP: Future of Family Medicine report (2003) - Medicine report (2003) - medical homemedical home•ACP: “advanced medical ACP: “advanced medical home” (2006)home” (2006)

PCMHPCMH• IBM, with employees all over the world, IBM, with employees all over the world,

concluded that they could buy high quality concluded that they could buy high quality care at reasonable cost in every country care at reasonable cost in every country except the US.except the US.

• Analysis: US needs strong primary careAnalysis: US needs strong primary care• IBM brought together AAFP, ACP, AAP, IBM brought together AAFP, ACP, AAP,

and American Osteopathic Association, and American Osteopathic Association, resulting in Joint Principles of the Patient- resulting in Joint Principles of the Patient- Centered Medical Home (2007)Centered Medical Home (2007)

National Committee for Quality Assurance National Committee for Quality Assurance (NCQA)(NCQA)

• Non-profit organization created by health Non-profit organization created by health plans in 1990plans in 1990

• Adopted 2007 principles of the PCMH, Adopted 2007 principles of the PCMH, creating a set of criteria for judging practicescreating a set of criteria for judging practices

• NCQA is certifying practices as being Level 1, NCQA is certifying practices as being Level 1, 2, or 3 PCMHs2, or 3 PCMHs

• Many primary care practices are trying to get Many primary care practices are trying to get NCQA recognition because it may bring NCQA recognition because it may bring higher reimbursementshigher reimbursements

• www.ncqa.orgwww.ncqa.org

PCMH-plus: Practice of the Future PCMH-plus: Practice of the Future • Barbara Starfield’s 4 pillars -- 4 C’sBarbara Starfield’s 4 pillars -- 4 C’s

– First First CContact careontact care– CContinuity of careontinuity of care– CComprehensive careomprehensive care– CCoordination of careoordination of care

• Recent additions to the 4 pillarsRecent additions to the 4 pillars– Patient-centered carePatient-centered care– Addressing the 15-minute visitAddressing the 15-minute visit– Team-based careTeam-based care– Computerized care linked to medical neighborhoodComputerized care linked to medical neighborhood– High quality care regularly measuredHigh quality care regularly measured– Concern with your entire panel of patientsConcern with your entire panel of patients– Everyone working at top of their skill levelEveryone working at top of their skill level– Controlling cost of careControlling cost of care

Practice of the Future: Practice of the Future: the paradigm shiftthe paradigm shift

• From From II to to WeWe: : – From the lone doctor with “helpers” to From the lone doctor with “helpers” to

the high-functioning teamthe high-functioning team– From my patients to our patientsFrom my patients to our patients

• From From He/SheHe/She to to TheyThey::– From a sole focus on individual patients From a sole focus on individual patients

to a concern for the team’s entire panelto a concern for the team’s entire panel

The paradigm shiftThe paradigm shift• Why do we need this change in how we Why do we need this change in how we

work with each other and how we care for work with each other and how we care for patients?patients?

• The lone doctor (“I”) model isn’t working The lone doctor (“I”) model isn’t working for adult primary carefor adult primary care

• The sole focus on individual patients isn’t The sole focus on individual patients isn’t working well enoughworking well enough

• What kind of medical & interprofessional What kind of medical & interprofessional education is needed to change the lone education is needed to change the lone doctor paradigm?doctor paradigm?

Practice of the future: Building Block #1Practice of the future: Building Block #12-part paradigm shift2-part paradigm shift

• From:From: How can the physician ( How can the physician (II) see today’s scheduled patients ) see today’s scheduled patients ((he/shehe/she), do the non-face-to-face-visit tasks, and get home at ), do the non-face-to-face-visit tasks, and get home at

reasonable hour?reasonable hour?

• To:To: What can the team ( What can the team (WeWe) do today to make the panel of ) do today to make the panel of patients (patients (theythey) as healthy as possible, and get home at a ) as healthy as possible, and get home at a reasonable hour?reasonable hour?

Monday Patients

8:00AM Sr. Rojas

8:15AM Ms. Johnson

8:30AM Mr. Anderson

8:45AM Sra. Garcia

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Practice of the futurePractice of the futureBuilding block #2Building block #2

• Primary care’s fundamental reliance on the one-Primary care’s fundamental reliance on the one-on-one face-to-face visit is obsolete on-one face-to-face visit is obsolete

• Patients may be cared for via multiple Patients may be cared for via multiple encounter modes – phone visits, e-mail encounter modes – phone visits, e-mail visits, distance encounters, visits to non-visits, distance encounters, visits to non-physician team members, group visits physician team members, group visits

• These depend on patient preference and These depend on patient preference and medical appropriatenessmedical appropriateness

• Factoria Clinic at Group Health in Seattle: Factoria Clinic at Group Health in Seattle: 1/3 face-to-face visits, 1/3 phone visits, 1/3 e-1/3 face-to-face visits, 1/3 phone visits, 1/3 e-mail visitsmail visits

Practice of the futurePractice of the futureBuilding block #3Building block #3

• Different patients have different needsDifferent patients have different needs Some only need routine preventive servicesSome only need routine preventive services Others need same-day acute careOthers need same-day acute care Some have one or two chronic conditionsSome have one or two chronic conditions A small number have multiple illnesses and A small number have multiple illnesses and

complex healthcare needscomplex healthcare needs Some have mental health/substance abuse needsSome have mental health/substance abuse needs Others require palliative or end-of-life careOthers require palliative or end-of-life care

• Each sub-group of a practice’s patient panel Each sub-group of a practice’s patient panel needs a different set of services by different needs a different set of services by different team membersteam members

Practice of the futurePractice of the futureBuilding block #4Building block #4

• No longer possible, given growing primary No longer possible, given growing primary care physician shortage, for physicians to care physician shortage, for physicians to care for all the patients in their panelcare for all the patients in their panel

• Physicians should care for patients Physicians should care for patients requiring the diagnostic and requiring the diagnostic and management expertise they havemanagement expertise they have

• Many routine acute, chronic and Many routine acute, chronic and preventive care needs can be handled by preventive care needs can be handled by other team membersother team members

• Requires huge change in physician Requires huge change in physician educationeducation

Practice of the futurePractice of the futureBuilding blocks 3 and 4Building blocks 3 and 4

• Stratify the patient panel according to needsStratify the patient panel according to needs Routine preventive services: medical assistants Routine preventive services: medical assistants

working as panel managersworking as panel managers Same-day acute care: NP/PA with MD consult as Same-day acute care: NP/PA with MD consult as

needed. Uncomplicated: RN with protocolsneeded. Uncomplicated: RN with protocols One or two chronic conditions: NP/PA working with One or two chronic conditions: NP/PA working with

medical assistants doing health coachingmedical assistants doing health coaching Multiple illnesses and complex healthcare needs: MD Multiple illnesses and complex healthcare needs: MD

with RN care manager with RN care manager Mental health/substance abuse: behavioral health Mental health/substance abuse: behavioral health

professionalprofessional Palliative or end-of-life care: MD with RN care managerPalliative or end-of-life care: MD with RN care manager

Practice of the futurePractice of the futureBuilding block #4Building block #4

• Physicians are clinical leaders of the team, see Physicians are clinical leaders of the team, see 8-10 patients per day, consult with team 8-10 patients per day, consult with team members, interact with patients by phone, e-mail members, interact with patients by phone, e-mail

• Entire team is responsible for panel of patientsEntire team is responsible for panel of patients• Culture change from Culture change from II to to WeWe• NPs/PAs care for the majority of patientsNPs/PAs care for the majority of patients• RNs do RNs do care managementcare management of complex patients of complex patients• Medical assistants/community health workers Medical assistants/community health workers

do do health coachinghealth coaching for patients with one or two for patients with one or two chronic conditionschronic conditions

• Panel managementPanel management by medical assistants by medical assistants

Practice of the futurePractice of the futureBuilding block #5Building block #5

• Fundamental change in payment for Fundamental change in payment for primary care (more and different)primary care (more and different)– Preferred is risk-adjusted capitation/global Preferred is risk-adjusted capitation/global

budget with extra payments for night/weekend budget with extra payments for night/weekend hours, panel management, good access/ hours, panel management, good access/ quality/costs/patient experiencequality/costs/patient experience

– If fee-for-service: e-visits, phone visits, and If fee-for-service: e-visits, phone visits, and visits to RNs, pharmacists, health educators, visits to RNs, pharmacists, health educators, health coaches must receive reimbursementhealth coaches must receive reimbursement

• Primary care practices and payers make Primary care practices and payers make compacts: practice improves, payer compacts: practice improves, payer increases and revises paymentincreases and revises payment

Panel managementPanel managementFrom He/She to They, From I to WeFrom He/She to They, From I to We

• Makes sure every patient has all chronic and Makes sure every patient has all chronic and preventive care tasks done on timepreventive care tasks done on time

• Every patient with poorly controlled chronic Every patient with poorly controlled chronic disease is offered planned visits and disease is offered planned visits and coachingcoaching

• Separates this work from the clinicians, Separates this work from the clinicians, leaving them time for more complex patientsleaving them time for more complex patients

Panel managementPanel management• Train medical assistant as panel manager Train medical assistant as panel manager • Physicians create evidence-based rulesPhysicians create evidence-based rules• Panel manager combs registry/data base, Panel manager combs registry/data base,

identifies patients who need services, contacts identifies patients who need services, contacts patients, orders servicespatients, orders services Preventive: mammograms, FOBT, Preventive: mammograms, FOBT,

immunizations, etc.immunizations, etc. Chronic: HbA1c, LDL cholesterol, diabetic eye Chronic: HbA1c, LDL cholesterol, diabetic eye

exams, blood pressures, etc.exams, blood pressures, etc. Identifies chronic patients in poor control, Identifies chronic patients in poor control,

arranges planned education/med arranges planned education/med adherence/lifestyle visits with RN, pharmacist, adherence/lifestyle visits with RN, pharmacist, health educator, health coachhealth educator, health coach

Panel management and Panel management and team buildingteam building

• Panel management: great way to build team; Panel management: great way to build team; allows medical assistants to share responsibility allows medical assistants to share responsibility for entire panel; they make sure chronic and for entire panel; they make sure chronic and preventive care routine tasks are performedpreventive care routine tasks are performed

• Physicians won’t delegate to other team members Physicians won’t delegate to other team members unless they are highly competentunless they are highly competent

• Other team members won’t accept job change Other team members won’t accept job change unless they share responsibility and pride for the unless they share responsibility and pride for the health of health of theirtheir patient panel (not the doctor’s patient panel (not the doctor’s patient panel)patient panel)

• Panel managers (and the entire team) should Panel managers (and the entire team) should share P4P moneyshare P4P money

Behavioralist

Health Coach PT

RN

Health Educator

PCP

Stratify the patient panelStratify the patient panel

31

RN Care Manager

PATIENT PANEL

Taking care of our panel (past)Taking care of our panel (past)

15-minute visit15-minute visit

15-minute visit15-minute visit

15-minute visit15-minute visit

E-mailE-mail

Health Health coachcoach

Panel management

e-Referrale-Referral

Return phone message

Return phone message

15-minute visit15-minute visit

15-minute visit15-minute visit 15-minute visit15-minute visit

15-minute visit15-minute visit

15-minute visit15-minute visit

32

Taking care of our panel (future)Taking care of our panel (future)

PATIENT PANEL

30-minute MD visit

30-minute MD visit

NP-led Group visit

NP-led Group visit

RN visitRN visitRN visitRN visit

E-mailE-mail

E-mailE-mail

Pharmacist Pharmacist visitvisit

Pharmacist Pharmacist visitvisit

E-consults with specialists

E-consults with specialists

Coordinate with

specialists, hospitalists

Coordinate with

specialists, hospitalists

Return phone messages

Return phone messages

E-mailE-mail

PA visitPA visitPA visitPA visit

E-mailE-mail

Telephone visits

Panel management

30-minute MD visit

30-minute MD visit

Health Health coach visitscoach visits

MD Trains/consult

s with team members

MD Trains/consult

s with team members 33

5:00 PM Catch up on notes/eReferrals

6:00 PM Return phone messages

7:00 PM Go home

Template of the pastTemplate of the pastTime Primary care

physician Medical assistant

Nurse Nurse Practioner

Medical assistant

8:00 Patient A Assist with Patient A

Triage Patient H Assist with Patient H

8:15 Patient B Assist with Patient B

Patient I Assist with Patient I

8:30 Patient C Assist with Patient C

Patient J Assist with Patient J

8:45 Patient D Assist with Patient D

Patient K Assist with Patient K

9:00 Patient E Assist with Patient E

Patient L Assist with Patient L

9:15 Patient F Assist with Patient F

Patient M Assist with Patient M

9:30 Patient G Assist with Patient G

Patient N Assist with Patient N

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Catch up on notes/eReferrals

Return phone messages

Go home

Template of the FutureTemplate of the Future

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Time Primary care physician

Medical assistant

Nurse Nurse Practitioner Medical assistant

8:00- 8:10 Huddle and make plan for the day’s work

8:10 AM

Telephone and e-mail visits -12 pts

Panel management

RN diabetes visits

Drop-in patients- 4 patients

Assist with drop-in

patients, close the loop,

phone follow-up

9:00 AM Patient D

9:30 AM

Coordinate with specialists and hospitalists. Consult with team members

Health coach visit with pt J

Group visit for chronic care – 12 patients

Patient K

10:00 AM

BP clinic- 3 patients

Join group visit for chronic care

Panel management10:15

AM Patient H and Patient BPhone outreach

Telephone and e-mail visits – 6

pts5PM Team signs out to overnight coverage and goes home…

Teamlet 1 Teamlet 2

From I to We: From I to We: challenge for interprofessional educationchallenge for interprofessional education

• Clinicians have most of knowledge and tell or ask Clinicians have most of knowledge and tell or ask other team members to do isolated tasks for themother team members to do isolated tasks for them– Do an EKGDo an EKG

– Do a blood sugarDo a blood sugar

– Get an O2 satGet an O2 sat

• Diffuse knowledge so that all team members Diffuse knowledge so that all team members become highly competent at the work they do become highly competent at the work they do

• Training is critical for team formationTraining is critical for team formation• Rather than isolated tasks, team members need Rather than isolated tasks, team members need

area of work for which they feel responsible, proudarea of work for which they feel responsible, proud• Physicians must learn how to delegate Physicians must learn how to delegate

responsibilities rather than ordering tasksresponsibilities rather than ordering tasks

Teams and teamletsTeams and teamlets• Well-functioning large teams are difficultWell-functioning large teams are difficult• Energy and time is taken up with multiple team Energy and time is taken up with multiple team

members having to communicate information members having to communicate information and coordinate tasks with each otherand coordinate tasks with each other

• If one person on the team is not cooperative, the If one person on the team is not cooperative, the entire team can failentire team can fail

• The smaller the teams, the betterThe smaller the teams, the better• 2-person 2-person teamletsteamlets (MD/RN,MD/MA, NP/MA, (MD/RN,MD/MA, NP/MA,

PA/MA)PA/MA)• Much easier to delegate with teamletMuch easier to delegate with teamlet

Bodenheimer, Building Teams in Primary Care, Bodenheimer, Building Teams in Primary Care, Parts 1 and 2. California HealthCare Foundation, 2007 Parts 1 and 2. California HealthCare Foundation, 2007 (www.chcf.org)(www.chcf.org)

Will patients accept team care?Will patients accept team care?

• Are teams patient-centered? Are teams patient-centered? • Patients may initially object since they Patients may initially object since they

want to see the doctorwant to see the doctor• Over time, if they get good care from Over time, if they get good care from

all team members, they begin to all team members, they begin to trust trust the teamthe team

• For continuity of care, teamlets are For continuity of care, teamlets are better than teamsbetter than teams

Interprofessional education:Interprofessional education:necessary for team buildingnecessary for team building

• From I to We is challenging for doctorsFrom I to We is challenging for doctors• The lone doctor model (taught in medical school) The lone doctor model (taught in medical school)

is deeply ingrainedis deeply ingrained• Without delegation of responsibility (not ordering Without delegation of responsibility (not ordering

tasks), teams do not worktasks), teams do not work• Reasons for not delegatingReasons for not delegating

– 1. No one to delegate to1. No one to delegate to– 2. Other team members not well trained2. Other team members not well trained– 3. Doc thinks he/she can do it all3. Doc thinks he/she can do it all– 4. Doc wants to see all the patients 4. Doc wants to see all the patients

• Interprofessional education can help with Interprofessional education can help with #3 and #4#3 and #4

Why are teams so crucial?Why are teams so crucial?Taming the perfect stormTaming the perfect storm

• Primary care access is deteriorating and Primary care access is deteriorating and quality is inadequatequality is inadequate

• Panel sizes too large for lone primary care Panel sizes too large for lone primary care physicians to managephysicians to manage

• We can’t reduce panel sizes due to worsening We can’t reduce panel sizes due to worsening shortage of PCPsshortage of PCPs

• Shortage means larger panels, poorer access, Shortage means larger panels, poorer access, more lone physician burnoutmore lone physician burnout

• The only solution to this perfect storm is The only solution to this perfect storm is teams, with physicians not having relationship teams, with physicians not having relationship with all patients on the team’s panelwith all patients on the team’s panel