Abstract
Background: Hybrid models of care (ie, telehealth and in-person care delivery options) have been incorporated into primary care clinics to increase patient access to care. We examine the effects of these approaches on the work experiences and wellness of primary care clinical team members providing team-based care to patients.
Methods: In this qualitative study, we conducted semistructured interviews with clinical team members (primary care clinicians, behavioral health consultants, registered nurse) at 2 primary care practices at 2 time points (late 2021-mid 2022 (n = 14); midlate 2023 (n = 11)). We used an inductive approach to analyze data.
Key Results: Benefits of hybrid models of care included increased patient access and personal flexibility; however, it was noted that the fragmented in-clinic schedules that emerged from the hybrid model resulted in reduced in-clinic interactions. This led to less information sharing among team members and a degradation of informal support networks that could adversely impact patient care. To mitigate these challenges, many preferred that most of their clinical shifts occurred in-person, in the clinic, with 1 to 2 sessions per week for in-home (telework) shifts.
Conclusions: In team-based primary care clinics, hybrid care models can impact interactions among clinical team members and shape the day-to-day environment in which clinical teams work. To optimize hybrid care approaches in the primary care setting, organization leaders must consider the impact of hybrid care models on clinic and team culture, and the well-being of clinical team members.
- Care Coordination
- Communication
- Health Services Accessibility
- Health Workforce
- Organizational Innovation
- Patient Care Team
- Primary Health Care
- Qualitative Research
- Telehealth
- Workplace
Introduction
Telehealth care, which we define as care delivered by phone or video, is now a common modality in primary care practices. Research highlights a number of benefits of telehealth, including increasing patient access,1–5 opportunities for remote work for clinical teams,1,2,6–8 and flexibility of scheduling for both patients and clinical teams due to the decreased burden of travel time.1,4,6 A number of challenges of telehealth care have also been noted including access and equity issues,1,4,9 infrastructure and resource needs,1 the impact of telehealth workflows on clinical teams,1,7,8,10 and how telehealth modalities effect communication and relationship building between patients and clinicians.2,8,11,12
Many practices do not deliver care exclusively via telehealth, but blend in-office and telehealth care for patients, what we refer to as hybrid care models. Hybrid models include both how patient visits are conducted (by telephone/video or in-clinic), as well as where clinicians conduct the visits (at-home vs in-clinic). By offering both telehealth and in-person visits, hybrid models can provide flexibility to meet the unique needs of individual patients. While research is growing regarding the adoption, implementation, use and impact of telehealth care,1–12 few studies have examined the implementation and impact of hybrid models on clinical teams.7,8
In prior work, we explored the impact of the incorporation of telehealth on the practice of delivering Opioid Use Disorder (OUD) care among interdisciplinary team members from 2 clinics within the same health system and patients’ experiences with telehealth delivery for OUD.2,13,14 These teams are composed of primary care providers (PCPs), behavioral health consultants (BHCs), and registered nurses (RNs) who provide care to patients in the general primary care practice, as well as to those patients receiving care for OUD. Before the COVID-19 pandemic, the majority of care was conducted in-person, in the clinic.2 Teams (eg, PCP, Medical Assistant, and nurse; the BH team) sat together in rooms (ie, in pods). In response to COVID-19, these clinics, shifted to a hybrid care delivery model, which allowed for both in-person and telehealth appointments for patients. It also accommodated clinical team members having a hybrid work schedule where some of the telehealth visits were conducted from the clinic and some remotely, typically from the clinical team member’s home. This model has been sustained postpandemic.
In this study, we examined the experiences of these clinicians in delivery of care, in general, within the hybrid care models implemented at their clinic to determine how these models affected clinical teams, including teamwork, operations, culture and well-being.
Methods
Study Design
This was an observational, cross sectional, qualitative study in which we conducted semistructured interviews with clinical team members (PCP, BHC, RN) delivering team-based care in primary care practices at 2 time points [Fall 2021-Summer 2022 and Summer 2023]. This study was approved by the Oregon Health & Science University Institutional Review Board (IRB).
Setting
This study was conducted in 2 clinics that were part of the same hospital system located in the Pacific Northwest; one was a Rural Health Clinic (RHC) and the other was an urban Federally Qualified Health Center (FQHC).
Participants
Clinical team members who provided care to patients with OUD, as well as to patients with other primary care or behavioral health needs, participated in this study.
Recruitment
Medical Directors at each clinic approved participation in the study. From among the clinical team, which delivered primary care and behavioral health care to patients in the clinic, these Medical Directors provided a list of clinicians (n = 16) who delivered OUD care. All participants were employed at these clinics before and during the COVID-19 pandemic, when telehealth visits were rapidly expanded. Ten clinical team members were initially contacted by e-mail, and interviews were conducted from December 2021-January 2022. Due to the influx of new and returning patients after the COVID-19 pandemic, and resulting limited availability of clinical team members, the project team was required to pause recruitment until August of 2022, when the remaining 6 clinical team members were recruited. One clinician declined to participate, and a care coordinator was excluded as they did not provide clinical care (n = 14; 5 rural and 9 urban). Understanding that the first round of interviews was largely conducted coming directly out of the COVID-19 pandemic, and with the hybrid care model being fairly new, we contacted these 14 clinicians again in June 2023 for a follow-up interview, to determine if the findings held true, once the protocols of the hybrid models of care were more established. One had left the clinic and 2 did not respond (n = 11 follow-up interviews).
Data Collection and Management
We conducted initial interviews of the clinical team from December 2021–January 2022. Remaining round 1 interviews were completed in August 2022. All follow-up interviews were conducted from July–August 2023. Interviews were conducted virtually (by video) and followed a semistructured guide (see Appendix A for the initial interview guide and Appendix B for the follow up interview guide) in which we asked a series of questions to prompt participants to reflect on both their experiences pre-COVID and their experiences delivering care during and postpandemic via different modalities (ie, in-person, telephone, video). The interview guides were pilot tested with primary care clinicians from the same hospital system but not from the included study clinics. Edits were made to the guide to improve clarity of questions. Interviews, which were conducted by 2 experienced researchers, lasted approximately 60 minutes, were audio-recorded, with permission, and professionally transcribed. Transcripts were reviewed for accuracy, deidentified, and were entered into ATLAS.ti Version 9 (Scientific Software Development GmBH, 2021) along with audio-recordings for data management and analysis.
Analysis
In using an inductive approach15 in our primary study aim, where we examined how clinical team members experienced the incorporation of telehealth care modalities in OUD treatment,2,13 data emerged around the personal experiences of clinical team members, and the impact of the hybrid model of care on clinical team members’ delivery of care and team collaboration, in general (eg, not just focused on OUD-related care), which we focus on in this article. Analysis of the first round of interviews focused on responses to 2 questions in the initial interview guide: “What has your experience been using virtual visits to deliver treatment to patients for opioid use disorder?” and “Can you describe for me how collaboration with the care team works when visits are conducted virtually?” Consistent with the aim of the second round of interviews to validate findings from the initial round of interviews, analysis of the second round of interviews used a deductive approach,15 with questions focused on clinical team members’ current experience of delivering care for all patients served by the clinic within the hybrid care model and clinician wellbeing: “In general, how is the clinic working together, and what different ways is the team communicating/working with patients?” and “How is this similar or different for OUD treatment” and “I am interested in how you are doing, what I am going to call – your personal wellbeing. How are you?”
After the first set of interviews in round 1, 3 team members (TWL, SW, SB) listened to and analyzed 2 interviews, which included discussion, and tagging text (eg, “clinicians’ personal experiences,” “collaboration among the team,” “clinician wellbeing,” “dedicated virtual schedule,” “providing remote care”) so that the analytic team could come back to select text for deeper comparison and sense making. Initial findings were then discussed with the larger project team, and it was at this time that the subthemes around the impact on the interdisciplinary clinical team and clinician well-being with the shift to a hybrid approach and asynchronous work were identified. TWL and SW then analyzed the remaining data, with a specific focus on the subtopics identified around the impact of providing care via telehealth. This process was repeated after the remaining first round of interviews (August 2022) and after the follow up interviews (Summer 2023). Regular meetings with the larger project team confirmed that saturation (ie, the point at which no new findings emerge from data collection) was reached.
After all interviews were analyzed, the qualitative team synthesized the data to make comparisons across clinical roles, differences in type of care delivered (eg, OUD care, general primary care or behavioral health needs) and time periods, with a focus on determining if experiences described in the first round of interviews continued to be described in the subsequent interviews. The primary difference between the time periods was the amount of time spent in a hybrid schedule. Over the course of the first interviews (December 2021–January 2022 and August 2022), the amount of time spent providing care via telehealth, either remotely or from the clinic was still evolving. During the follow up interviews (Summer 2023), the time spent providing care via telehealth and engagement (or not) in hybrid work schedules were more standardized. Participants’ reflections on their experiences had solidified during the follow up interviews, as they had more experience with the hybrid care model.
Results
Table 1 shows the number of participants we interviewed by clinic and professional role.
Number of Participants Interviewed by Clinic and Professional Role
Hybrid work environments were described as leading to more personal flexibility in the workday, ease in scheduling/conducting patient appointments, allowing for mental breaks to decrease the mental burden, particularly that associated with OUD care, and decreasing the environmental impact due to decreased transportation needs. Table 2 highlights the benefits participants saw with the hybrid care delivery model. Participants also described the value of regular communication with their team members to optimize patient care delivery, and how the hybrid work schedule impacted clinical team member communication patterns.
Clinical Team Members’ Descriptions of Benefits to the Hybrid Model of Care
Below we report findings related to how the hybrid model changed clinical work and collaboration patterns, both within the subset of interdisciplinary communication utilized for OUD care and among clinician’s broader care teams, highlighting the challenges clinical team members experienced and the impact of these changes on team culture and well-being. To demonstrate consistency of findings across the 2 time periods, illustrative quotes are included from each round of interviews for each finding below.
Information Sharing and Collaboration
Before the COVID-19 pandemic, teams described multiple forms of regular in-person communication. Team members shared offices, held meetings in-clinic, and engaged in informal exchanges (eg, running into a colleague in the hallway or during in-person meetings). In-person interactions provided opportunities for consultation, collaboration, and social support. Implementation of the hybrid model of care resulted in operational changes that physically separated clinical team members. This initially included a mandatory shift to a partially remote schedule for clinical team members, and a change in how clinic space was used (for example, behavioral health clinicians (BHCs) no longer shared office space). At the time of the second round of interviews, both clinics continued to support a hybrid work schedule and at one of the clinics the BHC continued to sit in their own room in the clinic, on their own.
Team members recognized the incorporation of a hybrid approach resulted in fragmented schedules and reduced in-clinic interactions. Clinical team members shared their experiences by contrasting in-clinic, team interaction with asynchronous team interaction due to hybrid schedules.
Our meetings used to be all in one room. Like we could kind of turn around and collaborate pretty quickly with each other and a little bit of that is lost… I do miss the in-person days as it were. – RN 1; Round 1, Interview conducted December 2021
Well, I think that having people in the building [again] has been a big positive, one for morale among staff, more camaraderie. People have relationships again. There's our whole team cohort that we have built up for over years in these pod systems. People are sitting together again… that pod-based, team-based care is where the magic happens because you can just turn around and be like, “Hey, can you give this patient—” or, “Hey, this is—I have this question. What do you think about this?” Instead of sending an in-basket message that's 12 hours later they get back to you, and it just—it improves how quickly care can happen…. I mean [the on-line messaging application] works great, but it's not the same as just, you know, sitting next to somebody. – PCP 7; Round 2, Interview conducted July 2023
Working together in the same space allowed team members to know how others on the team were doing during a clinic session, and adjust operations based on that, if needed. Nonvisual communication (eg, chatting via an online messaging application) with team members who were working remotely, and virtual meetings did not foster this kind of knowing, which was described as more personal and a way to get a pulse on how everyone on the team is doing.
It's easier to start seeing people less as people and more as place holders or role occupants. “Well, you're the BHC. I need you to do these things,” versus we're talking every day. I know those daily struggles, and I know that maybe today you're not in the greatest place to deal with this…I don't have that now, and so if I feel like I'm busy and I need somebody else to help, I'm just trying to turf it to the person who's occupying the role that's similar to mine without really knowing or considering what might be happening that would actually make me better suited to address [a patient care issue]. – BHC 8; Round 1, Interview conducted January 2022
If we could just talk things out in person, like we used to, really affects the way that we work… this push to be virtual, the push to have an agenda that is very objective, and the absence of agenda to just say, “hey, how are you doing? What’s going on in your life? What did you do this weekend?” is gone, and we see each other as so transactional and not as human beings. – PCP 10; Round 2, Interview conducted July 2023
Individual Clinician Wellbeing When Delivering Care via a Telehealth Modality
While clinical team members appreciated the evolution to a dedicated, regular hybrid schedule, a preference emerged that most of their shifts occur in the clinic, with in-person patient visits. During sessions delivered to patients via telephone or video (either from home or the clinic), team members reported feeling less engaged and more distracted during patient encounters and described work as being less enjoyable.
I feel exhausted after a half-day of virtual sessions. It's not quite as energizing as seeing people face-to-face, and you feel just a little bit like a robot. You're just typing as fast as you can, putting in orders, signing—all that stuff, and you don't really feel like maybe you did anything real. I think, from a satisfaction standpoint, most of us, we prefer a blend. – PCP 13; Round 1, Interview conducted January 2022
I think it's harder for me to stay engaged when it's virtually, especially when it's phone, 'cause I'm not looking at a person. I'm not in the room with a person. There's nothing to tie me to the connection, so I find myself having to try harder to stay connected. Not doing other things on my computer, not signing prescriptions or whatever. It's more of a challenge. - PCP 11; Round 2, Interview conducted August 2023
I've found my job satisfaction has dropped immensely with the transition to the new hybrid model. It’s so much harder to actually feel connected to people. In this business, my currency is connection, and I don't have that a lot of the time. At least not the ways that I experience it as such…. I imagine having a high-or at least a relatively high proportion of telephone visits doesn't help my feelings of connection to the job. It’s difficult to feel connected to the patients when I never get-you never get to see 'em or have any idea what they look like. I don't get to see their authentic reactions or really any of it. – BHC 8; Round 2, Interview conducted August 2023
To reduce the mental fatigue or decreased relational aspect of care, participants recognized the advantage of the hybrid work schedule. Clinic team members described 1 to 2 shifts per week for in-home, virtual care as being ideal. Having a clinical shift that blended in-person office visits and telehealth visits minimized the sense of loss from the absence of in-person in-clinic interactions with team members.
Discussion
As recognized by the National Academies of Sciences, Engineering and Medicine’s endorsement of the primary care telehealth rule revisions introduced during the COVID-19 pandemic,16 primary care adoption of telehealth is here to stay. And, similar to what was found in our study, there is evidence of tangible and intangible benefits for clinical team members when telehealth is incorporated into care delivery.1–8 Yet, there are many facets to a primary care team’s clinical success, and 2 critical components include the health of the individual clinic team members and the health of the clinical team.17,18 What we learned about the hybrid care delivery model is that it effects both the mental health of the individual team members, as well as team dynamics. This study provides a unique lens into clinical teams’ experiences with hybrid care delivery during 2 time periods and begins the discussion around factors clinical leaders need to consider when incorporating hybrid care models into their practices in a sustainable manner.
Through the implementation of hybrid policies and workflows, clinical teams have operationally changed the way they work together. Team members who used to work together in the same physical space may not see each other at all, see each other less frequently or engage in asynchronous work, even when copresent in the same office. Research has shown that the layout of a physical workspace can impact both the individuals who work in a space, as well as the work they are able to do together.19 In particular, being in close proximity to each other allows for increased visibility among team members, which in-turn enhances interprofessional interactions.20,21 It has also been shown that incorporating telehealth into primary care mental health integration can result in decreased communication between the behavioral health team and the primary care clinicians, and that extra effort must be made to engage clinical teams in interdisciplinary activities.10 As seen in our study, the absence of physical proximity when teams provide care asynchronously has the potential to affect the mental health of individual team members as well as the degree and type of communication and social relationships among team members. Although the impact of this degradation on the work of the individual or the social capital of the clinical team is not yet known, our findings do suggest that clinical leaders need to think carefully about how to achieve the right mix of care delivery options because the incorporation of telehealth has the potential to have both positive and negative effects for the team and the individual clinician in terms of burnout, well-being, and meaningful collaboration, all which in turn enrich patient care.18,22
Limitations
This article has limitations. The first is that we interviewed team members who worked together before the implementation of telehealth, and therefore we cannot explore the variation that would include a new team that did not have these relationships before the transition. Further, this can be seen as a special use case where teamwork among the interdisciplinary primary care team members who deliver care to patients with OUD is possibly more important than for other care delivered in primary care. And yet, when team members spoke about their care delivery practice, they were not exclusively talking about care provided as part of the OUD program, but rather about their daily rhythms and overall patient caseload, which included care for patients without OUD and engaging with other clinical team members outside of the OUD program. For this reason, although this exploratory work was conducted among a subset of clinicians who provide care to patients with OUD, we believe the findings are transferable to other team-based care. Second, there is a potential for recall bias, and it was possible that teams’ memory of how they worked together was clouded by the pandemic. Finally, although the first round of interviews in this study were conducted when in-person restrictions were still stringent in health care settings, teams had returned to sharing space in the follow-up interviews. And yet, some team members continue to work in isolation. Thoughtful consideration needs to be put into practice redesign moving forward to keep attention on clinician and clinical team well-being.
Conclusion
Our findings highlight the need for further work to be conducted with clinical teams to create a hybrid environment that mitigates the potential for isolation and supports collaboration. Specifically, larger scale studies are needed to understand the effect of hybrid models of care on teams, burnout, and patient care. As hybrid care delivery and work schedules are rolled out and expanded on, work needs to be done to consider the impact on clinicians, their colleagues, and the broader clinical teams, to navigate toward achieving a balance of the benefits of telehealth and the (sometimes) intangible benefits of in-person team engagement.
Appendices
Notes
This article was externally peer reviewed.
Funding: Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health (#1R21DA054261-01). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Conflict of interest: The authors have no conflicts to report.
To see this article online, please go to: http://jabfm.org/content/38/3/475.full.
- Received for publication October 25, 2024.
- Revision received December 12, 2024.
- Revision received January 27, 2025.
- Accepted for publication February 17, 2025.
