ACG GI Practice Toolbox: Team Based Care

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    Gastroenterologists in private practice find themselves working in a time of unprecedented transformation. Pressures are high as they make important management decisions that profoundly affect their business future, their private lives, and their ability to provide care to patients. The ACG Practice Management Committee has a mission to bring practicing colleagues together in order to explore solutions, overcome management challenges, improve operations, enhance productivity, and support physician-leadership. It was in this spirit that the Practice Management Toolbox was created.

    The Toolbox is a series of short articles, written by practicing gastroenterologists, providing ACG members with easily accessible information to improve their practices. Each article covers an issue important to private practice gastroenterologists and physician-lead clinical practices. They include a brief introduction, a topic overview, specific suggestions, helpful examples and a list of resources or references.


    Team Based Care

    AUTHOR:

    Stephen J. Utts, MD, MHCDS, FACP, FACG, Austin Gastroenterology, Austin, Texas

    The ACG Professionalism Committee

    INTRODUCTION:

    Team based care can increase practice capacity and efficiency through strategic redistribution of clinical work and documentation among members of a practice team. When all members of a health care team are practicing at the top of their license, care improves, time is freed for care coordination and provider engagement increases, reducing risk of burnout.

    TOPIC OVERVIEW:

    Clinical practice has undergone significant change over the past few years, with increasing emphasis on delivering value to patients coupled with increasing volume, increased documentation requirements, and the need to coordinate care across many providers. In the traditional practice culture, most of these responsibilities have flowed to the physician, who is the most expensive and time challenged resource. This care model is no longer sustainable if we are to be responsive to the increased demands for access and quality.

    Recently, there has been renewed interest in physician wellness and practice redesign to restore the joy of medicine. A growing body of evidence shows that well-functioning health care teams can increase provider capacity, improve outcomes and improve professional satisfaction.1-3

    Stable integrated teams coordinate care proactively and thus are better able to understand patient’s needs and can reduce wasted effort. Pre-office visit meetings can assure that test results, physician communications, and recent health events such as hospitalizations are entered into the patient record prior to the office visit. Redesign of rooming processes encourages all team members to contribute to electronic medical record documentation, reducing the burden on the physician. Medical scribes or medical assistants (M.A.’s) can assist in documentation during the visit. As team members learn to trust each other, some can be empowered to assume clinical duties that follow certain protocols. This includes appropriate delegation and sharing of tasks within the electronic medical record to reduce the size of the physician inbox.

    Once established, teams can continue to learn new ways to enhance efficiency and to provide new ways to engage patients and improve compliance. A team approach, utilizing dieticians and behavioral specialists has recently been proposed in the management of irritable bowel syndrome.4,5 Team care is especially important with patients with complex problems such as inflammatory bowel disease or cirrhosis. Expanded teams may be required to address nutrition, vaccinations and other health maintenance related biologic and immunosuppressive therapies or coordination of care with transplantation centers.

    PRACTICAL SUGGESTIONS

    1. Survey your practice culture for teamwork attitudes, then share results and look for areas of improvement. Find champions willing to commit to developing a team culture.
    2. Promote the benefits of creating highly functioning teams especially in improving professional satisfaction at all levels of the practice. Most practices are resistant to change as it requires some disruption of the normal processes, so be prepared to encourage and convince.
    3. Brainstorm for innovations. Brainstorming begins with an open non- judgmental flow of ideas, building on the ideas of all participants. This is followed by organizing the ideas by category, then choose one or two initiatives. The best ideas are easy to deploy but have the best potential to impact the practice.
    4. Implement in a pilot, usually with the most motivated teams. There will be a learning process, but with regular meetings the care path can be improved iteratively.
    5. Celebrate small wins and build on team cohesion and communication.
    6. Scale up through the practice and continue to develop new innovations.
    7. Measure improvements in patient and clinician satisfaction.
    8. Promote innovations with third party payers, marketing, and with referring physicians. This may position the practice to participate in alternative payment models, satisfying MACRA.

    The following is a testimonial on Team-Based Care for IBD from ACG Professionalism Committee member, Dr. Sara Horst:

    As a physician who cares exclusively for patients with inflammatory bowel disease, the past few years has been an exciting time as the number of medications to offer for inflammatory bowel disease treatment has increased. However, as this landscape broadens, so does the complexity of care. Insurance companies, infusion centers, specialty pharmacies, prior authorizations-the list of obstacles for patients and physicians to navigate together goes on and on.

    Also, this is often the tip of the iceberg for a patient with inflammatory bowel disease. Patients are so eager to understand many things including dietary changes. The importance of quality of care in inflammatory bowel disease is increasingly emphasized, including immunization management, bone health, and smoking cessation, to name a few. Patients with concomitant psychiatric issues such as depression potentially have worsened outcomes, so we are also potentially tasked with providing psychosocial care as well as caring for their GI tract.

    How can a physician tackle all of this successfully?

    This is where I have found the idea of team-based care so important. I work in a tertiary care inflammatory bowel disease center. We have dieticians in the clinic to give patients personalized dietary management strategies. There is a psychologist and social worker available to help address any psychosocial barriers that may be present. We have a clinical pharmacist to help a patient navigate through the insurance system.  Our nursing staff has immense knowledge of biologic medication administration and works within protocols to help with starting medications, refills, and ensuring appropriate follow up. In follow up visits, we have a team of physician extenders who are true experts in inflammatory bowel disease care and take the bulk of managing health maintenance issues.

    This incredible group allows me to focus on my true expertise: making sure we have the most appropriate overall management plan. The patient and I have time to form a doctor-patient relationship, which is immensely important as I will be potentially caring for them for the rest of their lives.

    Many providers do not have access to this team approach. It is expensive, insurance coverage can be difficult, and it requires significant care coordination.  However, most of the team care is based on protocols. I do believe that there are opportunities to take the burden of some of this care off the physician in any practice. A nurse visit to address health maintenance is an option. As dietary changes for many GI disease processes is gaining popularity, finding a dietician team to work with closely can be helpful. Short questionnaires for patient reported outcomes can alert practitioners to psychosocial issues that put the patient at risk for poor outcomes. Appropriately trained physician extenders can manage aspects of inflammatory bowel disease with physician oversight. Finding a center who could provide some of these team-based services and establishing referral networks for those at high risk for complications in the future may be useful.

    Inflammatory bowel disease is becoming more complex by the year, and I see team-based care as the way I will continue to be give quality care. As the idea of a medical home emerges, data suggests it may improve quality of life and outcomes in patients with inflammatory bowel disease. (1,2) I hope our health care infrastructure will start to better align with team-based care.

    1. Regueiro M, et al. Constructing an Inflammatory Bowel Disease Patient-Centered Medical Home. Clinical Gastroenterology Hepatol 2017; 15:1148.
    2. Regueiro M, et al. Reduced unplanned care and disease activity and increased quality of life after patient enrollment in an inflammatory bowel disease medical home. Clin Gastroenterol Hepatol 2018 Apr. pii: S1542-3565(18)30343-4. doi: 10.1016/j.cgh.2018.04.007. [Epub ahead of print]

    RESOURCES:

    The AMA Steps Forward modules are excellent, practical and well referenced. The National Academy of Medicine has a great search engine for team care articles and studies.

    1. https://www.stepsforward.org/modules/team-based-care
    2. https://www.stepsforward.org/modules/create-healthy-team-culture
    3. https://www.stepsforward.org/modules/team-huddles
    4. https://www.stepsforward.org/modules/team-documentation
    5. https://www.stepsforward.org/modules/pre-visit-planning
    6. https://www.stepsforward.org/modules/medical-assistant-professional-development
    7. https://www.stepsforward.org/modules/space-design
    8. https://www.stepsforward.org/modules/patient-discharge-and-rooming
    9. https://www.stepsforward.org/modules/lean-health-care
    10. https://nam.edu/clinicianwellbeing/?utm_source=National%20Academy%20of%20Medicine&utm_campaign=18b3d7fa9e-CR%20July%20meeting%20registration&utm_medium=email&utm_term=0_b8ba6f1aa1-18b3d7fa9e-150936445

    REFERENCES:

    1. Helfrich CD, et al. Elements of team-based care in a patient – centered medical home are associated with lower burnout among VA primary care employees. J Gen Intern Med 29(Suppl20: S659-66. DOI: 10.1007/s111606-013-2702-z
    2. Reid RJ, et al. The group health medical home at year two: Cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood) 29, No 5 (2010):835-843. DOI: 10.1377/hlthaff.2010.0158
    3. Linzer M, et al. Joy in medical practice: Clinician satisfaction in the healthy work place trial. Health Aff(Millwood) 36, No 10 (2017): 1808-1814. DOI: 10.1377/hlthaff.2017.0790
    4. Eswaran S, et al. Nutrition in the management of gastrointestinal diseases and disorders: the evidence for the low FODMAP diet. Curr Opin Pharmacol. 2017, 37: 151-157https://doi.org/10.1016/j.coph.2017.10.008
    5. https://www.GastroEndoNews.com/In-the-News/Article/04-18/Role-of-Dietitians-Expands-as-Diets-For-IBS-Gain-Favor/48360

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