Implementing High-Quality Primary Care Rebuilding the Foundation of Health Care (2021) / Chapter Skim
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6 Designing Interprofessional Teams and Preparing the Future Primary Care Workforce
6 Designing Interprofessional Teams and Preparing the Future Primary Care Workforce
Pages 181-224
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From page 181... ...
. This chapter focuses on the evidence supporting challenges and innovative solutions to creating interprofessional primary care teams that can offset the eroding capacity of primary care clinicians to deliver a broad scope of person- and family-centered care.
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From page 182... ...
, and because the needs of patients and their families will change over time, primary care teams should be able to evolve in response to those changing needs (Bodenheimer, 2019b; Bodenheimer and Smith, 2013; Brownstein et al., 2011; Coker et al., 2013; Fierman et al., 2016; Grumbach et al., 2012; Katkin et al., 2017; Margolius et al., 2012)
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relative to the population; health indexes for the population; the population's poverty level; and other demographic factors that affect the demand for services, such as the percentage of the population over age 65. Needs assessments similar to those produced by health centers can guide the efforts of primary care teams in conducting community health assessments of their own and inform the composition of the primary care team to match the specific needs of the community it serves.
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Interprofessional Primary Care Team 184 IMPLEMENTING HIGH-QUALITY PRIMARY CARE School-Based Support Behavioral Health Specialist Social Support Services Dentist PC Clinician Social Worker Pharmacist Medical Assistant Nurse Patient & Family Home Health Aide Care Manager Office Staff Community Health Worker Health Behavior Support Early Childhood Specialist Core Team Extended Health Care Team Extended Community Care Team FIGURE 6-1 The composition of interprofessional primary care teams. NOTE: PC = primary care.
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Stability ensures that members of the team work together consistently to support one another and that the team includes consistent individuals who care for patients and their families and can form stable relationships with them. The core, extended health care, and the extended community care teams require seamless, coordinated, and integrated care delivery processes to ensure that whole-person care is provided to each person.
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The study also found that shifting work from a physician-centric model of care to a shared, team-based model of care results in improved professional satisfaction and a greater joy in practice. Consistent with these findings, evidence is mounting that interprofessional primary care teams can improve care quality, reduce health care costs, decrease clinician burnout, and improve the patient experience, but this requires that teams are truly distributing the work and sharing the care responsibilities (Meyers et al., 2019)
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The following sections provide an overview of the core, extended health care, and extended community care teams. Each section highlights select team members and describes their roles and contributions on the interprofessional team.
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. Primary Care Clinicians The core team of primary care clinicians generally includes physicians, NPs, and PAs. Today, four major trends are strongly influencing the practice and expansion of interprofessional primary care teams: (1)
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general under-resourcing of primary care teams, and (4) scope of practice.
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. The resistance to increasing the scope of practice of any members of the core primary care team seems antithetical to the need to increase the number of primary care clinicians to expand access to care, particularly in underserved regions (Bruner, 2016; Buerhaus, 2018; Cawley and Hooker, 2013; Neff et al., 2018; Ortiz et al., 2018; Xue et al., 2018b)
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. Depending on need, members of this team can include CHWs, pharmacists, dentists, social workers, behavioral health specialists, lactation consultants, nutritionists, and physical and occupational therapists, who may support several core teams (Bodenheimer and Laing, 2007; Mitchell et al., 2019)
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These examples highlight the need for greater engagement of interprofessional team members, but the list is not comprehensive. Community Health Workers CHWs, also called "promotores de salud" and "peer mentors," are an important and emerging workforce within primary care.
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An integral part of the role of these team members is ongoing education, training, and consultation with medical team members to increase their comfort and confidence in identifying, treating, and managing comorbid mental and physical conditions and addressing a complexity approach to follow-up and team management to ensure continuity and engagement. A significant barrier for incorporating behavioral health into primary care is the growing shortage of behavioral health workers; the Health Resources and Services Administration (HRSA)
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. The VA has evaluated the extent of its success in integrating behavioral health into its primary care model and reported that primary care practices serving smaller populations experienced challenges in providing these services (Cornwell et al., 2018)
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. In recent years, HRSA has helped health centers tackle limitations in providing dental services, such as outdated equipment and insufficient space, to improve access to integrated, oral health services in primary care settings (HHS, 2019)
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, the percentage of primary care practices who report working with social workers may increase as public and private payers shift toward value-based payment models that emphasize addressing SDOH. Other Extended Health Care Team Members In addition to those described above, many other health care professionals may be part of the extended team and contribute value-added care and services to meet the needs of the person seeking care.
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The Extended Community Care Team An essential component of the interprofessional primary care team is the extended community care team, which includes organizations and groups, such as early childhood educators, social support services, healthy aging services, caregiving services, home health aides, places of worship and other ministries, and disability support services. This brings together the community organizations, services, and personnel who are dedicated to ensuring that health care teams, care-seekers, and communities have access to the support services and resources needed to ensure the health and wellness of people and communities.
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For a 10,000-person panel with a larger proportion of geriatric individuals, the authors modeled a larger team with about 52 members, more devoted to complex care management. For a 10,000-person panel with high social needs, the team included about 50 members but relatively fewer physicians compared to the other models and with additional members, such as CHWs, behavioral health, and other social supports.
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. EDUCATING AND TRAINING THE INTERPROFESSIONAL PRIMARY CARE TEAM Chapter 3 touched briefly on the pipeline problems for primary care workforce production.
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Interprofessional education competencies are location agnostic, so there is no guarantee that aspiring primary care–bound health professionals, as well as the existing primary care workforce, have any interprofessional education or training specific to the delivery of primary care. Integrating interprofessional education and training in primary care is also a challenge because crowded clinics often find that accommodating single students from one discipline is disruptive to the normal workflow.
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. Having a diverse health care workforce that reflects the population has been shown to improve health equity and reduce health care disparities, increase access to care, improve health care outcomes, strengthen patient communication, and heighten patient satisfaction in underserved and minority populations (COGME, 2016; Cohen et al., 2002; Cooper and Powe, 2004; HRSA, 2006; Poma, 2017; Wakefield, 2014)
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Among internal medicine residents in 2020, 4.7 percent were Black and 6.7 percent were Hispanic. Among family medicine FIGURE 6-2 Age distribution of primary care physicians in 2017.
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This is a reflection of the systemic discrimination and biases evident in education, housing, finance, and job opportunities that funnel minorities to health care support and personal care service roles as opposed to health diagnosing and treating roles. Approaches such as holistic admissions practices benefit racial, socioeconomic, and perspective diversity of health professions schools, but the work to improve representation in health care extends far beyond admissions processes (Urban Universities for Health, 2014)
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. While CHWs can improve the diversity of the extended primary care team, that should not deter the necessary efforts to diversify the core primary care workforce across professions to create a local workforce that reflects the diversity of the community in which it is practicing, which can lead to a more equitable system for all (Cohen et al., 2002)
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FUNDING TO SUPPORT THE TRAINING OF THE PRIMARY CARE WORKFORCE The ability to obtain high-quality primary care depends on the availability of clinicians who are essential members of the primary care core team, including PCPs, NPs, and PAs (Phillips and Bazemore, 2010)
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and Children's Hospitals Graduate Medical Education (CHGME) funding for physician workforce training results in only 24 percent of trainees pursuing primary care, and fewer than 8 percent go to rural practice (Chen et al., 2013a)
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demonstration project, mandated under Section 5509 of the Patient Protection and Affordable Care Act (ACA) ,5 was designed to test whether payments for clinical education increased the number of NP graduates, with the aim of increasing the supply of primary care clinicians to meet growing U.S.
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. These findings are similar to those reported by the National Association of Community Health Centers that health centers are twice as likely as other primary care practices to employ NPs, PAs, and CNMs.
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. NHSC clinicians help enhance care delivery in community health centers, particularly for dental and mental health services, which are the two major areas of service gaps.
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Alternative financing sources are needed for community-based training of physicians, NPs, and PAs in primary care. Primary care practices, with high patient volumes and limited time and resources, need financial incentives to support the intensive training of interprofessional primary care teams.
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2015. National community health worker advocacy survey.
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2019b. Building powerful primary care teams.
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2012. Teaching health centers: A new paradigm in graduate medical education.
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2020. Embedding social workers in Veterans Health Administration primary care teams reduces emergency department visits.
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2019. The role of the national health service corps clinicians in enhancing staffing and patient care capacity in community health centers.
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1989. Primary care physicians: Financing their graduate medical education in ambula tory settings.
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2015. From rhetoric to reality -- community health workers in post-reform U.S.
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2020. Recognizing and sustaining the value of community health workers and promotores.
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:44–51. NACHC (National Association of Community Health Centers)
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2020. Community health workers and COVID-19 -- addressing social determinants of health in times of crisis and beyond.
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2019. Evolving models of integrated behavioral health and primary care.
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2016. The behavioral health workforce needed for integration with primary care: Information for health workforce planning.
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2005. Informal learning in postgraduate medical education: From cognitivism to "culturism." Medical Education 39(8)
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2018a. Federally quali fied health centers reduce the primary care provider gap in health professional shortage counties.
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