Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system

doi:10.1007/s11606-018-4611-7

Comparative Study

. 2018 Nov;33(11):1928-1936.

doi: 10.1007/s11606-018-4611-7. Epub 2018 Aug 6.

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system

Anita D Misra-Hebert^{1

2

3}, Adam Perzynski⁴, Michael B Rothberg^{5

6}, Jaqueline Fox⁶, Mary Beth Mercer⁷, Xiaobo Liu⁸, Bo Hu⁸, David C Aron⁹, Kurt C Stange¹⁰

Affiliations

¹ Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA. misraa@ccf.org.
² Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA. misraa@ccf.org.
³ Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA. misraa@ccf.org.
⁴ Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth, Cleveland, OH, USA.
⁵ Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.
⁶ Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.
⁷ Office of Patient Experience, Cleveland Clinic, Cleveland, OH, USA.
⁸ Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
⁹ Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA.
¹⁰ Center for Community Health Integration, and Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, Oncology and Sociology, Case Western Reserve University, Cleveland, OH, USA.

PMID: 30084018
PMCID: PMC6206362
DOI: 10.1007/s11606-018-4611-7

Comparative Study

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system

Anita D Misra-Hebert et al. J Gen Intern Med. 2018 Nov.

. 2018 Nov;33(11):1928-1936.

doi: 10.1007/s11606-018-4611-7. Epub 2018 Aug 6.

Authors

Anita D Misra-Hebert^{1

2

3}, Adam Perzynski⁴, Michael B Rothberg^{5

6}, Jaqueline Fox⁶, Mary Beth Mercer⁷, Xiaobo Liu⁸, Bo Hu⁸, David C Aron⁹, Kurt C Stange¹⁰

Affiliations

¹ Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA. misraa@ccf.org.
² Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA. misraa@ccf.org.
³ Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA. misraa@ccf.org.
⁴ Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth, Cleveland, OH, USA.
⁵ Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.
⁶ Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.
⁷ Office of Patient Experience, Cleveland Clinic, Cleveland, OH, USA.
⁸ Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
⁹ Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA.
¹⁰ Center for Community Health Integration, and Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, Oncology and Sociology, Case Western Reserve University, Cleveland, OH, USA.

PMID: 30084018
PMCID: PMC6206362
DOI: 10.1007/s11606-018-4611-7

Abstract

Background: Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care.

Objective: To identify practice setting components contributing to uptake of new team-based care models.

Design: Convergent mixed-methods design.

Participants: Employees and patients of primary care practices implementing two team-based models in a large, integrated health system.

Main measures: Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team.

Key results: Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups-high, partial, and low uptake of new team-based models. Uptake was related to (1) practices' responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices' ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices.

Conclusion: Uptake of new team-based care delivery models is related to practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.

Keywords: Health care delivery; Primary care redesign; Qualitative research.

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Conflict of interest statement

Dr. Misra-Hebert has received research funding from the Merck Investigators Studies Program and from Novo Nordisk, both unrelated to this work. Drs. Perzynski, Rothberg, Hu, Aron, and Stange, and Ms. Fox., Mercer, and Liu report no conflicts of interest.

Figures

**Figure 1**
Convergent mixed methods study design.

**Figure 2**
Differentiating characteristics of practices influencing uptake of new delivery models.

See this image and copyright information in PMC

Comment in

Capsule Commentary on Misra-Hebert et al., Implementing Team-Based Primary Care Models: A Mixed-Methods Comparative Case Study in a Large, Integrated Health Care System.
Kong M. Kong M. J Gen Intern Med. 2018 Nov;33(11):1958. doi: 10.1007/s11606-018-4643-z. J Gen Intern Med. 2018. PMID: 30203356 Free PMC article. No abstract available.

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References

1. Mitchell et al. Core Principles & Values of Effective Team-Based H.pdf. https://www.nationalahec.org/pdfs/vsrt-team-based-care-principles-values.... Accessed July 5, 2018.
1. Green LV, Savin S, Lu Y. Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication. Health Aff (Millwood) 2013;32(1):11–19. doi: 10.1377/hlthaff.2012.1086. - DOI - PubMed
1. Home|PCMH Resource Center. https://pcmh.ahrq.gov/. Accessed July 5, 2018.
1. Patient Aligned Care Team (PACT) - Patient Care Services. https://www.patientcare.va.gov/primarycare/PACT.asp. Accessed July 5, 2018.
1. Joint Principles of the Patient-Centered Medical Home. https://www.aap.org/en-us/professional-resources/quality-improvement/Pag.... Accessed July 5, 2018.

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[1] Mitchell et al. Core Principles & Values of Effective Team-Based H.pdf. https://www.nationalahec.org/pdfs/vsrt-team-based-care-principles-values.... Accessed July 5, 2018.

[2] Mitchell et al. Core Principles & Values of Effective Team-Based H.pdf. https://www.nationalahec.org/pdfs/vsrt-team-based-care-principles-values.... Accessed July 5, 2018.

[3] Green LV, Savin S, Lu Y. Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication. Health Aff (Millwood) 2013;32(1):11–19. doi: 10.1377/hlthaff.2012.1086. - DOI - PubMed

[4] Green LV, Savin S, Lu Y. Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication. Health Aff (Millwood) 2013;32(1):11–19. doi: 10.1377/hlthaff.2012.1086. - DOI - PubMed

[5] Home|PCMH Resource Center. https://pcmh.ahrq.gov/. Accessed July 5, 2018.

[6] Home|PCMH Resource Center. https://pcmh.ahrq.gov/. Accessed July 5, 2018.

[7] Patient Aligned Care Team (PACT) - Patient Care Services. https://www.patientcare.va.gov/primarycare/PACT.asp. Accessed July 5, 2018.

[8] Patient Aligned Care Team (PACT) - Patient Care Services. https://www.patientcare.va.gov/primarycare/PACT.asp. Accessed July 5, 2018.

[9] Joint Principles of the Patient-Centered Medical Home. https://www.aap.org/en-us/professional-resources/quality-improvement/Pag.... Accessed July 5, 2018.

[10] Joint Principles of the Patient-Centered Medical Home. https://www.aap.org/en-us/professional-resources/quality-improvement/Pag.... Accessed July 5, 2018.

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Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system

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