Flexible implementation and integration of new team members to support patient-centered care

Background: Central to the patient-centered medical home model are high functioning interdisciplinary teams, which aim to improve care coordination and patient self-management of chronic conditions. We examined the facilitators and barriers of implementing a primary care team redesign intended to augment physician-medical assistant dyads by adding two new care team members - registered nurse care managers [NCM] and patient health coaches [PHC].

Methods: To assess respondents׳ experiences of role integration, 22 key informant interviews were conducted of primary care physicians, NCMs, PHCs, and medical assistants at pilot practices (n=5). Additionally, a clinician and staff survey of 400 respondents was conducted at pilot and non-pilot (n=28) practices to contextualize the redesign results.

Results: Respondent experiences differed due to flexible protocols in program implementation, intended to allow each care team׳s approach to be site specific. Three sites struggled in developing processes that best used each new member, often due to poor comprehension of the member׳s scope. Successful practices (n=2) reported increased team communication and functioning as a result of high physician engagement and local leadership facilitation.

Conclusions: Flexible implementation protocols gave practice stakeholders significant discretion to integrate new care team roles to best fit local needs. The flexibility, however, created ambiguous expectations of the redesign, resulting in inconsistent implementation of key features of the intended redesign in some practices.

Implications: When implementing primary care teams across practice networks, standardized scope of practice of personnel, common quality improvement priorities, and shared performance metrics may be helpful in disseminating effective redesign strategies.