organization with seven primary care sites scattered throughout San Diego County. Founded in 1969, Neighborhood Healthcare began as an all-volunteer clinic in Escondido and is now a Federally Qualified Health Center providing services to 64,000 people with more than 200,000 annual visits. Ninety-eight percent of patients have incomes below 200 percent of the federal poverty level. The organization has 350 staff members including physicians and nurse practitioners; 75 percent of funds come from the federal, state, and county governments. Chief medical officer is James Schultz.
Neighborhood Healthcare has made two impressive innovations in primary care team formation: primary care teamlets with clinicians and medical assistants, and diabetes teams in partnership with another community organization, Project Dulce.
Primary Care Teamlets
In contrast to larger teams involving several clinicians, RNs, pharmacists, health educators, medical assistants, and receptionists, teamlets are teams of two people — a clinician (physician or nurse practitioner) and an MA. Neighborhood Healthcare’s teamlets feature an expanded role for the MA in the primary care encounter.
Neighborhood Healthcare recently undertook a primary care redesign initiative, based on the work of Roger Coleman’s patient visit redesign consulting group. With Coleman’s team assisting in the redesign of one site, the Neighborhood Healthcare leadership spread this improvement to all sites. As a result of the redesign work, cycle time — the time between the patient’s arrival and departure from the clinic — dropped from an average of 114 minutes to 30 to 45 minutes for patients with appointments and under 60 minutes for drop-ins. Almost all visits are scheduled for 15 minutes, with three appointments scheduled each hour, leaving one slot per hour for drop-ins. Monday mornings, Friday afternoons, and winters more slots are left open for drop-ins.
Clinicians see about 24 patients per day.
Going far beyond the usual redesign process, Neighborhood Healthcare decided that MAs should become directly involved in patient care, taking on tasks that clinicians formerly performed KEy ElEMENTS
Type of practice community health center (FQHC)
Locations seven primary care sites;
San Diego County, CA Patient population 64,000 patients;
98 percent low-income Team care innovations 2:1 ratio of medical assistants
to clinicians
but that do not require professional training. This teamlet approach is similar to that of the University of Utah (see case study 14).
Four primary care sites have been fully redesigned to support the teamlet approach. These sites have adopted a staffing ratio of two MAs to each clinician (physician or nurse practitioner). The leadership experimented with 1:1 MA/clinician ratio and three MAs for each two clinicians. They found that the model only works with a 2:1 ratio. With two MAs for each clinician, a clinician can see one extra visit each day, which — given the augmented Medi-Cal payments afforded federally qualified health centers — pays for the additional MAs. As much as possible, the same clinician works with the same two MAs. Close to 60 percent of patients are Spanish-speaking, with all MAs bilingual in Spanish. MAs perform pre-visit, visit, and (informally) post-visit functions.
During the pre-visit, the MA does the usual vital signs and other activities (blood glucose checks, urine dipsticks, peak flows) based on the patient’s diagnoses or symptoms. MAs perform a portion of the medication reconciliation work, noting on the paper-chart medication list which medicines are being taken and which are not. They do not usually inquire why patients are not taking all their medications. At the conclusion of the pre-visit, the MA calls the clinician. If the clinician is ready, he/
she joins the MA in the exam room; if not, the MA may do another task such as a phone call, making sure rooms are stocked with all needed materials, or looking for lab or X-ray results that may not be in a patient’s chart.
When the clinician enters, the visit begins; the MA translates if needed, fills out lab, X-ray and referral forms, makes referral appointments for the patient, and may assist with prescription refills. Different clinicians work with MAs in different ways. For example, some call out their physical exam findings and have the MA check the appropriate boxes on the physical exam form. Clinicians have found that they
have less paperwork and fewer phone calls at the end of the day, and are getting home earlier. They are very happy with this system; one nurse practitioner moving to another state couldn’t imagine how she could go back to the old way of doing things.
Neighborhood Healthcare has not organized a formal post-visit session, but patients may ask the MA some questions or provide additional information after the clinician leaves the room. The MA may need to check back with the clinician if significant issues emerge.
The MAs are trained to schedule appointments for patients, to make referrals to specialists, and to work with clinicians in a flexible manner, depending on what the clinician wants. The training is on-the-job.
The MA turnover rate is 20 to 30 percent per year, but some stay many years.
Diabetes Teams with Project Dulce Primary care sites with insufficient trained personnel can partner with other community organizations to create teams with the proper skill mix. Neighborhood Healthcare has created such a partnership with Project Dulce, a highly-regarded diabetes program sponsored by the Whittier Institute for Diabetes.
Project Dulce is a diabetes care and education program that, since 1997, has addressed the needs of underserved, ethnically diverse populations. The program offers two services: diabetes education groups led by promotoras (many of whom have diabetes) and a diabetes care management team consisting of an RN/certified diabetes educator), MA, and dietitian. Seventy-two percent of patients who have utilized one or both of Project Dulce’s services are Latino, 68 percent have annual incomes below $10,000, and 51 percent have an eighth-grade education or lower. Project Dulce’s patients have achieved significant improvements in HbA1c, blood pressure, and lipids measured against a comparison group and the national average.23
Building Teams in Primary Care: 15 Case Studies | 1 At Neighborhood Healthcare sites, a Project Dulce
care management team of an RN/certified diabetes educator and two MAs comes on certain days, providing planned diabetes visits with Neighborhood Healthcare patients in close coordination with the patient’s primary care clinician. Some of these planned visits are with one patient; in other cases, they involve group visits, generally with 10 to 12 patients at a time. As part of the group process, clinicians see their patients individually.
In summary, Neighborhood Healthcare has leveraged both its internal resources (MAs) and external resources (Project Dulce) to create teams that both improve care and enhance clinician work life. This model of partnering to gain expertise not available in a primary care site is particularly useful for small private primary care practices and community clinics.