Article Figures & Data
Tables
Before PCMH Project (Facilitation of patient flow through office) After PCMH Project Implementation (Patient care/population management) Call and escort patients to examination room Obtain family and social histories, reconcile medications and chronic problems lists, document cancer screenings Take and record vital signs and chief complaint Give injections, draw blood, perform EKGs or other procedures per physician order during patient visit Pre-visit planning (chart reviews, huddles) Carry out standing orders and protocols (give immunizations, provide mammogram orders/lab forms, refill routine medications) Give out patient education handouts per physician request during patient visit Proactively hand out patient education materials (eg, smoking cessation) Conduct patient education using motivational interviewing (eg, weight, diabetes) Organize/conduct patient awareness campaigns to address preventive care, eg, through telephone calls, wearing buttons on shirts, mailings Call for results as per physician request during patient visit Gather documentation of preventive services, other metrics, consultations, and hospitalization reports prior to patient visit Give reports that come into office to physicians Track, manage and enter data into electronic medical record/other data management tools File charts Assist with risk stratification of patients EKG, electrocardiography; PCMH, patient-centered medical home.
Barriers Sample Quotations Insufficient MA understanding of the PCMH concept I (researcher) asked if there is ever conversation between her (MA) and the doctors about the [PCMH program]. She said no…she wishes they talked about it more in this practice. She feels that the MAs understand their new tasks, but she doesn't feel that they understand the “PCMH or any of the pilots.” Her understanding of the concept of the PCMH is “to have the patient feel comfortable and confident that we will take care of all their medical needs.” (fieldnote, Practice 10) [The MA] knew about the metrics and was able to name BMI and smoking as examples. She said, “It's not really a change but now we do things 100% of the time”… like taking someone's BMI every time they come in which is, “kinda dumb…especially for acute visits.” (fieldnote, Practice 9) Lack of time for added responsibilities [The MA] gets concerned sometimes when more tasks are added “because more responsibility means that it takes longer.” She said that when 4 clinicians are working and there's only one MA rooming, it can get very stressful. (fieldnote, Practice 15) Additional workload without additional pay [The PCC] has heard that there has been some turnover and there is good amount of frustration within the ranks of the MAs. Apparently they haven't had raises in 3 years and the demands of the job are increasing—they are citing this kind of work as an example of something that is adding to their workload. (fieldnote, Practice 9) Lack of MA knowledge or training One thing [PCC] is frustrated by is that she feels for the most part, the MAs are just “memorizing tasks and not really thinking.” She (PCC) has been surprised by the low level of clinical knowledge that the MAs have. For instance, she said that one MA asked her if a high PT/INR meant that it is thick or thin. [The PCC] said that when she was talking to MAs about the metrics, one of them said, “Good luck getting patients to get a colonoscopy,” and someone else said (regarding colonoscopy), “What? Does [insurance company] want patients to live forever?” (fieldnote, Practice 10) [If I could change one thing] I think that it's getting the medical assistants to think more like doctors, and to kind of function without being told, doing things without being told… we have mostly medical assistants, they don't really think like nurses. They're not that trained…nurses think differently, but they cost a lot more money…. I think the medical assistants try, but they just don't have that knowledge base enough to kind of anticipate…So that's the price we pay for hiring lower trained people. And I guess that you can train them. They're reasonably smart; they're not dumb. But, it takes a lot of work. (physician interview, Practice 9) Reluctance to delegate tasks to MA [A nurse practitioner commented that] the MA shouldn't be allowed to do the patient's health maintenance (ie, fill the standing orders that the health maintenance screen says the patient needs). “They just see it as a checklist and they treat it that way. It's not a checklist!” She explains that if a patient has not gotten a test or followed up on something they've been told to follow up on, then just re-ordering probably isn't going to help. She said that health maintenance “should be a conversation.” (fieldnote, Practice 4) Uncertainty on how to make workflow changes more routine [Handing out smoking cessation handouts] was not part of the routine initially; it was new and it wasn't getting done all the time… [The health plan] was good at telling us what they wanted us to do, but not really how to do it. You know, they wanted these metrics, they wanted these reports, they wanted…but there wasn't a lot of help. We were trying to figure it out ourselves. (physician interview, Practice 1) Staff turnover One office manager described this as bittersweet. An MA of eight years who had trained in the practice since her internship had gradually been entrusted with increased responsibilities, developed skills, and become a practice leader. Based on the competencies the practice had nurtured in her, she was able to secure a new position at the local hospital that included higher compensation and tuition support for her nursing program. (fieldnote, Practice 6) Change fatigue The MAs worked so hard last summer—they busted their [butts] pulling charts. Now, that's all over, but then it was this iPad Depression screening project that had a 27-page manual for them to read, and then [this PCMH project] came in—so it's just been a lot. (Clinical supervisor, Practice 9) BMI, body mass index; MA, medical assistant; PCMH, patient-centered medical home; PCC, population care coordinator; PT/INR, prothrombin time/international normalized ratio.
Facilitators Sample Quotations Explanation of how new MA responsibilities fit within the broader PCMH practice transformation goals [The MA] reiterated that she thinks [Doctor], [Office Manager], and [Population Care Coordinator] do a really good job of explaining exactly what they want for the QI projects. She said the staff generally takes orders well, but that it's easier when they understand and appreciate the goals of the project and get good instructions …She has a pretty robust understanding of PCMH, about care coordination, about the importance of patients getting the disease follow-up and preventive care that they need, and about why they collect so much data. (fieldnote, Practice 12) Extra training [The PCC] tells me that the MAs feel uncomfortable talking to a patient about the patient's weight (or smoking) when they themselves (the MAs) are overweight and/or smoke…. [She] is coaching the MAs on how to approach difficult topics with a patient…. [The office manager] also has mentioned this coaching as one of the things she believes [PCC] excels in doing, and that she has noticed a difference in how the MAs are working with patients. (fieldnote, Practice 9) Detailed protocols and standing orders They have standing orders for chronic disease management as well, so, for example, they have standing orders for diabetic labs. They use a screening questionnaire before administering vaccines too. For diabetic retinal screenings, they have a form they use to get the eye doctor to send back the results. (fieldnote, Practice 13) Open communication The first way to make sure that staff buy-in happens is communication, communication, communication…we allow the staff to ask questions, or to question why we're saying we should do things this way, because no one truly understands unless they see the big picture. So the staff doesn't feel that this is what I do because I have to do it. Hopefully, they understand the process and the reason why they're doing what they're doing. (Office Manager interview, Practice 5) Initial small and achievable goals [The MA] said they had decided to start with the smaller goals first and after that to work on the bigger goals. Medication reconciliation was a small goal, whereas screenings will be a bigger goal. Another bigger goal is to have less patients running to the emergency room, which she says they can work on by encouraging better control and compliance. She gave the example of making sure CHF patients take their water pills every day by instructing them on the importance of doing this. (fieldnote, Practice 6) Compensation for extra efforts They have a new feedback system that goes along with the bonuses for doctors and staff, part of which [the lead physician] bases on their engagement with the PCMH and QI initiatives currently underway…. Everybody accepts the system and understands why they are doing the projects that they are doing, and what role they each play in the overall plans. (fieldnote, Practice 12) MA, medical assistant; QI, quality improvement; PCC, population care coordinator; PCMH, patient-centered medical home.
In this issue
Jump to section
Related Articles
Cited By...
- Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures
- The Financial Cost of Medical Assistant Turnover in an Academic Family Medicine Center
- Association between full monitoring of biomedical and lifestyle target indicators and HbA1c level in primary type 2 diabetes care: an observational cohort study (ELZHA-cohort 1)
- Real-Life Observational Studies Provide Actionable Data for Family Medicine