As Obamacare expands access, clinics use team care to adapt

By Maggie Jones, MPH, Associate Director of the Center for Community Health and Evaluation at Group Health Research Institute

Under Obamacare, millions of Americans are gaining health coverage, which is providing them with access to much-needed care. This is a positive direction for public health. But I also see, every day, how challenging this momentous change is for community clinics. At the Center for Community Health and Evaluation (CCHE), we work closely with people who fund and carry out programs and initiatives to improve community health. Two of our recent partnerships responded to the effects of Obamacare on safety net clinics, which provide treatment regardless of patients’ ability to pay. We evaluated programs that were designed to help these clinics adapt to ongoing health care reform.

Under Obamacare, states can choose to expand Medicaid. California took this opportunity to increase health care access to people who struggle to get medical services. Of course, expanded coverage means more patients can seek care, so already busy safety net clinics braced themselves for thousands of new patients. Two private philanthropies in California, Sierra Health Foundation and Blue Shield of California Foundation (BSCF), stepped up to help. The programs they funded are helping clinics deliver care differently, benefiting both patients and staff.

Schedule jockeying and team-based care

Both foundations, starting in 2013, gave grants to community health centers to explore and test ways to increase capacity. Hiring more doctors and nurses wasn’t an option because of a workforce shortage and limited space, so the clinics had to figure out how to wring more out of their existing resources. The two foundations supported slightly different approaches: Sierra Health gave grantees operational support, for flexibility in reconfiguring to meet rising demand. In the BSCF program, grant recipients enhanced team-based care, a proven model for increasing efficiency. Team care experts from the MacColl Center for Health Care Innovation were partners in the BSCF work. CCHE helped with development, implementation, and ongoing evaluation of both foundation-funded initiatives. Our final evaluation reports are online for Sierra Health and for BSCF.

Even with the differing strategies used by the two foundations, we saw common challenges, solutions, and lessons learned. Many clinics worked hard on more efficient scheduling: reducing no-shows and being more facile about making appointments. For example, clinics empowered front desk staff to “jockey the schedule”—fill the daily schedule by matching cancelled visits with people requesting same-day appointments.

Team-based care was used to maximize efficiency in the BSCF-funded clinics and some Sierra Health-funded sites. A common strategy of team care is to restructure roles, responsibilities, and workflow so all clinic personnel do as much patient care as possible. We call this “working at the top of their license.” An example is creating protocols and standing orders so nurses can make common medication adjustments. This frees up physicians for more complicated care issues. The good news about these innovations is they are sustainable: They provide ongoing benefits without a lot of additional funding.

Clients, staff, and doctors all win

Team-based care innovations help clinics serve patients better. We also found these innovations have positive effects on clinic employees, by letting them fully use their training and skills. These job changes help health care professionals fulfill their career objectives of engaging in patient care and developing relationships with the people they serve. Since we also noted a perceived increase in patient satisfaction in our program evaluations, these innovations benefit everyone.

I see a trend in these two initiatives and other programs that CCHE has evaluated recently. As we reform health care, providers and staff at safety net clinics will feel overwhelmed with the changes. Our work shows that, with support from sources like Sierra Health and BSCF, clinics can increase capacity and serve both existing and new patients. Clinics do this by delivering care differently, like implementing team care, which is a win for staff and their patients.

Learn more

Here are three helpful resources that your practice can use to get started with team-based care:

  • Primary Care Team Guide: Practical advice, case studies, and tools from 31 practices across the country that have markedly improved care, efficiency, and job satisfaction by transforming to a team-based approach.
  • Implementing team-based care, a module from the AMA STEPS Forward™ practice transformation series: Evidence on the practical impact of team-based care, step-by-step implementation guidance, plus resources to help with implementation (CME credit offered).
  • Creating Patient-centered Team-based Primary Care, from AHRQ’s Patient-Centered Medical Home Resource Center: A blueprint for patient-centered team-based care, plus practical strategies that different types of practices can use to support implementation.

Maggie Jones, MPH, manages evaluation services at Group Health Research Institute’s Center for Community Health and Evaluation. She oversees CCHE’s portfolio of evaluation projects and leads many of its large scale evaluation efforts related to community health improvement, clinical quality improvement, health policy, health equity, and public health training programs.

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