Change Your Primary Care Mindset--the Rest of the Team

“Gosh, Curmudge, I haven’t seen you this excited since you last had your hearing aid adjusted. What’s up?”

“Jaded Julie, it’s really gratifying to learn that a simple concept, which we now call ‘empowerment,’ is being used in health care. Many years ago I worked in an organization where empowerment and respect were a way of life but were never verbalized. I first learned a name for this concept when the Army used it as a recruiting slogan, ‘Be all you can be.’ Now the concept is an essential element of the primary care medical home leading to enhanced patient care and staff professional fulfillment.”

“It’s a big leap from the military to primary care, but I’m sure that you will help me make the connection. As usual, we’ll start by describing what the staff—other than the physician—did in the traditional primary care clinic.”

“Traditionally, nurse practitioners (NPs) and physician assistants (PAs) worked fairly independently or otherwise in close collaboration with physicians, as allowed by state regulations. In some instances there was even an element of competition with primary care physicians.”

“I know about the clinic nurses, Curmudge. They roomed the patients, did histories and vitals, and performed straightforward procedures like injections. If I had been in that situation, I would have wondered why I studied so hard in nursing school. Of course, for older nurses it was easier on the back and feet than working in a hospital’s patient care units.”

“And the clerical help in the traditional clinic were not much different from a receptionist or a filing clerk in a law firm. That situation would be difficult for a person who wants a job with a purpose, in which she can do worthwhile work, and make a difference.”

“Curmudge, for an old guy who forgets a lot, you seem to remember Quint Studer’s Healthcare Flywheel (1) pretty well. So how does the medical home get these people out of the ruts they are in, change their mindset, and allow them to ‘be all they can be’?”

“As I said last week, Julie, the leader (physician) empowers his or her colleagues (the rest of the team) by giving them permission to reach their potential. This, in addition to its primary focus on the patient, is what a medical home is all about. Let’s start with the NPs and PAs, the so-called midlevel providers. In a medical home team they work closely with the physician and sometimes near the limit of their ability and certification. In doing so, they free up the physician to treat those cases that require the full scope of his/her training and experience.”

“Maybe I’m as old fashioned as you are, but if I’m going to see a midlevel provider, I’d prefer it to be in a clinic with a doc in the next room than in a store front or a drugstore. Although clinical decision-support resources are expanding the capabilities of midlevel providers, the medical home—where I know everybody and everybody knows me—is where I’ll find personalized care. So, Curmudge, what about the RNs, LPNs, and medical assistants (MAs)?”

“In the medical homes that I’ve read about the RN no longer rooms patients. He or she is often the clinic’s principal contact with patients with chronic diseases. Only rarely do these patients need to see the physician, and sometimes a phone call or an e-mail note to their RN will resolve their problem. In clinics where the RN works closely with the physician, she can become the physician’s surrogate and provide the same answers to patient questions as the physician would (recall our 9/03/09 posting). The bottom line is that in a medical home, the patient sees or communicates with the best clinician equipped to handle his/her problem; and that’s not always the physician.”

“I can see how this saves a lot of the physician’s time.”

“The LPNs or MAs, sometimes called Health Care Associates, perform the rooming duties formerly done by the RN. That would include medication reconciliation, history, and perhaps part of the physical exam. The extent of their involvement in patient care depends on their interests, demonstrated capabilities, and the systems established at the clinic.”

“I can tell you about the clerical staff, Curmudge. A better name is Patient Service Representative. In addition to their traditional role, they manage record-keeping and inter- and intra-clinic communications and may have an expanded role in telephone triage. Much depends on the clinic’s electronic systems. Those with broader interests can become cross-trained with Health Care Associates.”

“So you see, Julie, a lot of good things can happen in a clinic with a well-led, empowered staff.”

“As we said back on February 18, 2008, ‘Hoo-ah, sir.’ ‘Be all you can be.’”

Affinity’s Kaizen Curmudgeon

(1) Studer, Quint. Hardwiring Excellence. (2003, Fire Starter Publishing)