High-volume team based care - one end of the medical home spectrum

A nice piece in Business Week online about primary care and the medical home highlight Dr. Peter Anderson's practice in Newport News VA.  He works with a large staff and sees 30-35 patients a day, has nurses spend the bulk of time with the patients.

"The history-taking just kills the doctor's time. I don't have to do any of that," Anderson says.

This is one end of the spectrum of practice models that can theoretically deliver care that leads to better patient outcomes, improved experience of care, and make health care more affordable because it lowers the total cost of health care.

Cory Sevin, others and I published an article about creating high functioning teams.*  We know that a highly trained, highly choreographed team can - through careful intention, measurement and continual attention - achieve very good results.

But just like sports teams, we cannot assume that all teams are 'high performing.'  We must not presume that 'team' in and of itself will achieve good results.  Barbara Starfield points out the lack of literature supporting 'teams' as an intervention to improve population health:

Family medicine appears to have acceded to the concept of the “patient-centered medical home” (PCMH), but proposals for the PCMH are not very patient-centered. They are justified on the basis of evidence regarding the benefits of primary care, but the criteria for assessment of PCMHs, such as those promulgated by the National Committee for Quality Assurance, concern organizational features such as electronic health records, computerized guidelines and amorphous “teams,” none of which have been demonstrated to be pursuant to good primary care. - Starfield B.  Family Practice Management

I love that Dr. Anderson is innovative in his practice delivery and that he's been able to demonstrate some good results (though to be honest, there's not much "patient-centered" about achieving the NCQA recognition). 

As we work to create effective delivery systems, let there be a range of solutions.  I want to point out in particular that solo and small practices have demonstrated their ability to deliver patient-centered care that meets very well Dr. Starfield's definitions & that we've published the results.

Let folks build practices of many sizes and shapes so long as they commit to measuring and displaying the highest levels of quality.  Just don't tell me that solo & small practices are unable or unwilling to deliver high quality care (I'm speaking to some researchers & policy makers out there who believe the only way our nation will improve care is by forcing all docs into systems like Geisinger, Kaiser & Group Health - great systems to be sure, but why force the model).

We have done the work.
We have demonstrated the results.
We have done this IN SPITE of a system that systematically degrades and impedes effective primary care.
Where insurance rules make it impossible to deliver high quality care, we have done this in many cases by stepping out from under the crushing and impossible burden of insurance company nonsense.

We don't need anyone's permission to create high quality effective primary care.
We don't have to adhere to mistaken and tangential definitions of what constitutes a "medical home."

We're doing this work because it is the right thing to do for our patients.

L. Gordon Moore

*Sevin C, Moore G, Shepherd J, Jacobs T, Hupke C.  Transforming care teams to provide the best possible patient-centered, collaborative care. Journal of Ambulatory Care Management 2009 Jan-Mar;32(1):24-31.

Comments

[jean]

"The history-taking just kills the doctor's time. I don't have to do any of that," Anderson says.

Hmm,since history taking gets the diagnosis most of the time, a sad state of affairs it is that doing our job sucks up too much time so we find ways to get someone else- lower paid-- to do our job ,becasue our job sucks up too much of our time.
TIME being more important than OUR JOB .
No disrespect to Dr A intended but, who's on first??

[Kent]

I agree. I have no interest in practicing that way.