Coastal Medical, an accountable care organization (ACO) in Rhode Island, ranks third in the nation for quality among 333 Medicare Shared Savings ACOs and is a member of the IHI Leadership Alliance. Meryl Moss is Coastal’s Chief Operating Officer.
Health care entities are in the process of designing the organization and structure that supports population health management. We are striving to meet the Triple Aim: improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care. This is a big transition for the industry.
Many of us are making the commitment to this exciting new work, but we have many questions: What types of information do we need to make informed decisions? How do we create the right structured data fields in the record so that we can run registry reports? How do we streamline processes and workflows to ensure that our organizations achieve quality metrics and close gaps in care for broad populations?
We undoubtedly need these answers, but there are many other questions we must address first: Who should be doing this new, complex, sophisticated, and nuanced work? Who should be on our clinical teams? What types of employees should be supporting those clinicians? How do we combine clinical and operational skills and best practices so that patients get care that is both effective and efficient?
Rethinking the Patient-Centered Medical Home Team
Who should be on patient-centered medical home teams seems fairly intuitive: nurse care managers, pharmacists, behavioral health specialists, physicians, and advanced practitioners. They are the diagnosticians, caregivers, and coordinators of patient care. They are educated, professional, smart, highly compensated, and in demand.
However, we soon realized that medical assistants could also play a major role in the work. We could shift tasks to them that physicians, advanced practitioners, or nurse care managers do not need to do, including reconciling a patient’s medication list, noting a patient’s flu vaccine in a structured data field, or administering a basic depression screen. Over time, medical assistants have become more and more responsible for directly engaging patients and working on filling gaps in care by doing things like ensuring that diabetic patients get eye exams, neuropathy screenings, and laboratory tests. This might also include making sure that frail elderly patients have fall risk screenings, bone density tests, and dementia screenings.
To meaningfully interface with patients, engage them in their care, and document appropriately in the record, a medical assistant needs to be highly trained. Coastal developed a medical assistant training program that includes instruction on medication reconciliation, pre-visit planning, and electronic health record documentation. Supervisors conduct annual reviews that assess performance and competency levels.
Providing the training medical assistants need to increase their responsibilities has multiple benefits. Giving them the opportunity to more directly contribute to care increases the well-being of their patients and which can help medical assistants to take more satisfaction in their work. It also means they can free up the time of others on their team.
Reversing Traditional Roles Between Clinical and Operational Teams
Coastal also discovered that clinical teams need support from the operational side of the organization in ways that are new and different. As health care organizations develop innovative ways to care for patients, we need people in our data, quality, and even financial departments who can offer ideas and solutions to support these new approaches to care. We are looking for answers, not obstacles.
For example, in the past, those in the finance department might have assumed that it was their role to focus solely on profitability, accountability, cost, and revenue. This new approach reverses traditional roles. Instead of asking clinical programs to support the financial foundation of the organization, we ask how finance can support patient care.
Clinicians are the architects and designers of the care models, but they require experienced and pragmatic administrators to make it happen. These skilled individuals must know how to listen and understand the clinical vision before they can act. To be effective, they must facilitate teams of experts in finance, human resources, IT, data, contracting, and marketing to operationalize a clinical program. It takes a special type of leader and a unique operational team to put aside departmental differences and solely work to implement the clinical vision. This approach has to be unconditionally collaborative.
Working Without a Roadmap
The difference between this new work and our traditional approach to health care is that there is no road map. Organizations are learning as we create new models of care. We need employees who can flourish and grow in a continuously changing learning environment. Individuals who value structure, clearly defined roles, and tight work boundaries will be unhappy in an organization that identifies change and creativity as the norm.
Health care organizations of the future will depend on nimble, sophisticated, and creative employees to meet their objectives. These employees will be motivated by what they can accomplish and will be deeply connected to the organization’s mission. They will value their contribution to change and get joy from working with others on a common goal. These employees will make a difference in the health care of populations and the lives of patients.