September 24, 2018

Workforce and Patient Centered Medical Homes

Carol Moser

I was recently appointed to the State Health Workforce Council and was asked to give my perspective on the health needs of our region. While our strategy has evolved since developing our Regional Health Improvement Plan in 2016, the Theory of Action that we identified -- systems integration, community engagement, coordination of care and health equity/social determinants -- have remained our pillars. We find those pillars in the Patient Centered Medical Home (PCMH) model of care. Led by the primary care team, PCMH organizations work in teams of integrated specialists and with community partners to address chronic illness, social determinants, patient engagement, and proactively manage their patients using population health management tools. The PCMH model is the perfect fit for aligning our four project areas, target populations and strategic issues. It also provides a good foundation for providers to be successful in a value-based payment (VBP) system.
But what about workforce? How does the PCMH model fit in the current needs for healthcare workers? Just as healthcare has to adapt its care model to address the needs of the patient, the workforce model has to adapt to the needs of healthcare providers.
At the top of the list is allowing providers to practice to the full extent of their education and training, instead of spending time doing something that could be effectively done by someone else. In a PCMH clinic, the care team addresses the patient needs through medical, behavioral, and social care coordination. A typical team might include the primary care physician, a registered nurse, a behavioral health specialist, a layperson or Community Health Worker (CHW), a Medical Assistant and a pharmacist, but the key is that it is team based, each contributing to the care of the patient...
For example, an average panel size per full time equivalent (FTE) physician is 2,000, demanding approximately 6,000 face-to-face visits of which the normal physician only has time for 4,400 visits. Team-based care can increase that capacity by as much as 2,400 visits by taking most preventive, chronic, uncomplicated acute care, and behavioral health issues off the physicians’ shoulders. 
Since most of our region experiences shortages in primary care and behavioral health care, PCMH is an excellent way to expand the existing capacity of the primary care workforce. Additionally, physicians derive higher job satisfaction from the PCMH model, and are more attracted to practices that are PCMH.
So, what does the current and future state vision for workforce look like?
  • Clinical leaders consistently champion and engage clinical teams in improving the patient experience by providing time, training, and resources
  • Practice teams are supported by a quality improvement infrastructure that involves patients and families
  • Staff other than the PCP performs key clinical service roles that match their ability and credentials
  • Workflows are documented and standardized
  • The practice ensures that staff are appropriately trained for their roles, and cross-trained to make sure patient needs are consistently met
  • Medical assistants play a major role in preventative services to chronically ill such as self-management coaching
  • RNs provide care management for high risk patients and collaborate with the providers in teaching and managing patients with chronic illness
  • Behavioral Health is an integral part of the care team or readily available through a referral protocol or agreement.
  • Laypersons (CHWs) provide self-management coaching, coordinate care, help navigate the system, or access community services. They are a key component of the practice team.
What can and should our Workforce committee and GCACH staff be concentrating on?
  • Relationship building! Developing partnerships with high schools, Community and Technical colleges and Universities to create pathways for healthcare careers.
  • Advocating that licensure and scope of practice policies are addressed at the state level to remove barriers to physical and behavioral health integration.
  • Ensuring that members of the care team know how to function in a team-based setting and have been trained in trauma informed practice.
  • Funding and finding scholarships for students interested in healthcare fields, especially in professional shortages like nurses, dental assistants, and behavioral health specialists.
  • Identifying all the community resources within our region so that our providers can connect with community-based organizations (CBOs) that address the social determinants of health.
To truly make a difference in health outcomes, we must become the transformers of our healthcare systems.  We must try to raise the quality of care and improve care coordination across all care settings. Working together, we can move all the cogs in our Theory of Action.