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Teamlet Task List
Pre-visit
Huddle with clinician to set goals
Agenda-setting with patient
Medication reconciliation — document the
patient's Rxs Ordering routine services (standing
orders) — BP, glucose, ECG, urine, etc
History taking using
questionnaire devised with MD
Visit
Clinician does history taking, diagnosis
and care management
Health coach takes notes
and orders necessary tests, fetches equipment
Post-visit
Soliciting patient concerns — health
coach asks patients if they have questions or
worries
Closing the loop —
recap diagnosis, instructions, referrals and medication
Goal setting — negotiate
action plan, encourage behaviour changes
Between-visit follow-up
— health coach calls or emails patients to
reinforce advice given at visit
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Finding the time to give your chronically
ill patients the care they need is one of the biggest
challenges facing primary care physicians today.
Offloading some non-clinical duties
to members of a "teamlet" could ease that burden and
improve your patients' outcomes, says Dr Thomas Bodenheimer,
a family doc at the University of California, San Francisco.
For the past couple of years Dr Bodenheimer's been involved
in pilot projects to test the teamlet approach. He describes
the model in the current issue of the Annals of Family
Medicine.
TEAMLET
PLAYER
The ideal teamlet consists of one clinician and two
health coaches. The coaches' role is to support the
clinician and perform tasks that don't require the doc's
medical skills, such as lifestyle coaching and filling
in paperwork (see Teamlet Task List below for a full
run-down). This frees up the doctor to concentrate on
diagnostic and care management duties.
The teamlet approach is targeted
at patients with chronic conditions. "High blood pressure,
diabetes, high cholesterol — or some combination
of those," explains Dr Bodenheimer by phone from San
Francisco.
In a utopia, the coaches would
be nurse practitioners. "But they're too expensive,"
he says. In the real world, you're more likely to use
medical assistants or, if you're really lucky, RNs.
"Most medical assistants have very little training,"
says Dr Bodenheimer, but in his experience most of them
are ready and able to take on the extra duties.
But that'll cost you extra, right?
"That could become an issue," admits Dr Bodenheimer.
"Fee-for-service is a terrible way to pay — there's
no interest in having a team." But Dr Bodenheimer says
he does know of some fee-for-service practices that
have adopted similar approaches on the basis that more
patients can be seen — though he worries that could
just end up putting more pressure on docs.
Dr Bodenheimer is the first to
admit the teamlet approach is no cure-all. "It's not
good for reducing the time it takes to get an appointment
and it's not good for acute patients," he says. "But
it's a good model for solving some of the problems of
primary care." Asked what 'quick-fix' aspects of the
teamlet model he'd recommend to his Canadian colleagues,
without hesitation he says "medication reconciliation.
That could save the doc a lot of time."
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PATIENTS & PRACTICE
