A deeper look into the way your patients experience care delivery can provide a new perspective into how your team coordinates care from the waiting room to the exam room to the parking lot. Learn four simple, physician-authored questions you can ask your patients to find out if your practice is meeting their needs.


The AMA’s STEPS Forward™ collection, written by physicians from the Stanford University School of Medicine, shows you how to analyze your patient population’s clinical needs to build an intensive primary care practice. Check out the “STEPS in practice” section of the module to see how it’s working at Stanford.

Though the module is designed to build an intensive primary care practice, knowing the care delivery experience and needs of your patients can help any practice type.

Engaging patients and asking them these four questions may give your practice a better understanding of opportunities to improve your care process:

  • What is the worst thing about your health situation?
  • What in your life helps to make the situation better?
  • What does medical care do that helps make the situation better?
  • What does medical care do that doesn’t help your situation or makes it worse?

Once you’ve gathered your patients’ answers to these questions, you will have a clearer picture of what kind of changes your practice can make to better meet their needs.

For physicians in primary care who are looking for ways to better keep their patients healthy, the intensive primary care practice may be an option to consider. An intensive primary care practice comprehensively addresses the goals and medical needs of patients with multiple chronic conditions whose needs would likely not be met in a short primary care visit.

In this type of practice, it is important to provide patients with expanded in-person and remote access to the care team. The STEPS Forward module offers several options for bolstering your medical staff to address this type of practice setting.

For instance, medical assistants can perform routine care and act as a coordinator to see patients through the care process. Also, bringing more registered nurses on board can shift some responsibilities in providing direct patient care. They can work more closely with the extended care team once the physician’s assessment is complete. Similarly, hiring advanced practice clinicians, such as nurse practitioners and physician assistants, who can exercise advanced clinical responsibilities can aid in continuity and coordination of care.

Other team members, such as receptionists, dietitians or diabetes educators may round out your practice team if your patients’ needs require such additions. The reality is that most practices likely will not be able to hire a full-time care coordinator or health coach. Instead, you can identify existing members of your care team who have the proper interpersonal skills and send them for training so they can focus on those activities.

You may want to add certain specialized professionals to your care team if coordinating with physicians outside your practice isn’t working for patients. These may include:

  • A behavioral health specialist for patients who experience depression or other similar issues is often helpful. For example, you might look for a licensed clinical social worker with the combined skills of a social worker and a therapist.
  • Adding a physical therapist to your care team could help streamline care coordination for patients with chronic pain who are having trouble making it to their appointments with physical therapists outside of your practice.
  • A clinical pharmacist could add value to the team as well. This person can help patients understand their medications, promote adherence and adjust medications accordingly while continuing a dialogue with the care team.

More than 25 modules are available in the AMA’s STEPS Forward collection, and several more will be added later this year, thanks to a grant from and collaboration with the Transforming Clinical Practices Initiative.

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