Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Jill Jin, MD, MPH: Hi everyone. And welcome. This is Dr Jill Jin, senior physician advisor at the AMA. On today's episode, we will be discussing an advanced team-based care model for primary care that is in use at Heartland Health Centers in Chicago. Specifically, this model involves the role of an advanced medical assistant called a care team coordinator or CTC. And I have two guests with me today, both from Heartland Health, Dr Jeff Panzer, family physician, and VP of care transformation, and Erica Deming, care team coordinator who works with Dr Panzer. Thank you both so much for joining me.
Erica Deming: Thanks for having us.
Jeff Panzer, MD, MPH: Thanks, Jill. It's great to be here.
Dr Jin: Erica, why don't we start off with a little bit more about you. Can you tell us a little bit more about your role and duties as a CTC and how it differs from that of a traditional medical system?
Deming: Well, yes, so I work with Jeff. He goes by Jeff on our care team. So, I've been working with him, with one other care team coordinator. I used to work as a medical assistant and already that's pretty different because you usually work one-to-one with a provider. And as a medical assistant, you are bringing the patient back to the room, getting their vitals, like blood pressure and temperature. And then you're asking the basic question. What's the reason for your visit? And they might say ankle pain, and you would just write that down. And then I would leave the room, let the provider go in. And then that visit would happen behind closed doors. And there's other tasks involved, too. There's vaccines and point-of-care tests and stuff. But as a care team coordinator, I get to actually join during the visit. So that's not happening behind closed doors anymore. And I get to help in a bunch of different ways and in kind of different ways for each patient when I'm with the provider and the patient together.
Dr Jin: And what kinds of ways specifically?
Deming: So first and foremost, I'm documenting their conversation. So, I'm actually writing in the assessment and plan which problems they're getting to and what each of them are saying about it. The provider will ask me to put in some labs for the patient to do so I'll prep those, I'll prep medications for them to sign later. I'm often coordinating between different professionals, too. So, if there's mental health professionals that I'm coordinating with to see if we can do a warm handoff or pulling in results from other hospital systems in real time during the visit. So, in that way, there's pretty much a laundry list of kind of so many different things I could be doing. And just depending on the patient, we kind of tailor to their needs.
Dr Jin: Got it. So, in addition to the traditional clinical and rooming duties of the MA you're also doing documentation, sounds like a big one, and then also pending orders and referrals and doing some coordination with other specialists.
Deming: Yes. And then one other big difference is that after the provider's part of the visit is done, I do the visit discharge where I can reiterate the provider's instructions and give them their papers and explain what the next steps are. And I can do that in a little bit more detail and provide more education to the patient because I was there for the visit.
Dr Jin: Dr Panzer, anything to add to that?
Dr Panzer: Yeah, I think that in addition to some of the technical things that Erica and other care team coordinators are doing, they're also building relationships with patients and through those relationships able to identify things in their history for example, that I, I wouldn't have been able to get. It's very frequent when a care team coordinator, after I've already left the room, will come back to me and tell me that the patient didn't necessarily agree with the plan, but didn't feel comfortable speaking of it. There's another set of eyes, ears, and another relationship that's formed between patients and care team coordinators. That's important.
Dr Jin: And that's interesting. So, it's almost like another layer of trust with a care team member.
Dr Panzer: Yeah, exactly.
Dr Jin: So, Erica, you wrote an email recently to your dad who is also a physician about how fulfilling your role as a CTC has been to you. And I remember it was kind of shared with our team and it was, uh, late in the evening email that felt very genuine and very heartfelt. And when we at AMA STEPS Forward® read it, we felt it was very special because it really embodied the essence of team-based care and team culture that we are striving for. Would you mind sharing with our listeners some of what you wrote?
Deming: Sure. So, I shared this email with him for a couple reasons. One is because he worked as a primary care provider too, and he worked very hard in our small town. And for me, it was just personally very exciting to work on a project where there was an element of shared workload of documentation during the visit. So, I thought that was exciting, but I also was just excited about my role that I got to be a part of the care a little bit more closely. So, I'll read you a little bit about what I was telling him about our model. My teammates and I have just been excited by how much we're able to get done with this model. Every day is a whirlwind of fairly complex patients, but we weather it exceptionally well as a team. During a regular 15-minute visit, I'm documenting extensively in the EMR, coordinating with referral specialists and behavioral health counselors, and pulling results from other health systems while the provider is talking to the patient. I clean up problems lists, the medications list, and I enter orders. The providers tell me how now that they're just looking at the patients, they notice more cues and facial expressions that lead to new topics of conversation that deepen their care. We even navigate the schedule with more flexibility, seeing late patients, because many struggle with transportation and adding patients who need to be seen.
Dr Jin: Yeah. I love reading that paragraph about just how much you came together as a team and how you took on challenges with excitement and energy. And you felt like it was a whirlwind but in a good way. And you felt very empowered in your role to be involved, which that's the whole goal of what we're trying to do. You talked about a patient. Do you want to talk more about that?
Deming: Yeah. So, there was a patient that I got to take care of with another provider at our clinic who ended up being on hospice care. And so, I got to be a part of his end-of-life care. And actually, my dad now works as a hospice provider. So, I was wanting to share that experience with him and just how special it was to be a little bit closer to his care through the model. So, for this patient, it was pretty special because we prioritized continuity of care between the care team coordinators and the patient. So, we made it a priority for me to see him every time for the visit over the phone, during the pandemic. And I felt like I got to know this person and it was just very special that I think the provider also encouraged our connection with him.
And I actually got to be on the phone call when she was explaining that his care had become palliative, but there was another day that we were just on a phone call with him for a visit that felt very special within this model because we were able to care for him together. So, I'll read a little bit about that. A few weeks ago, when I called this patient for his telehealth visit from the hospital, Asha, the nurse practitioner I worked with, and I found that he was struggling to breathe and his call light wasn't working. Together we searched the records for his floor, Asha called the hospital. And I stayed on with him until I heard a nurse arrive and help him. That was a really striking experience for me. So it seems almost trivial to point out that during all of this, my coworker, another CTC, Alma, was getting the next patient ready, but it's experiences like this, our connection with this patient, and our ability to care for him together and our sustainable ability to see the rest of our patients in the day that increasingly convinced me that a team model like this could make the difference in primary care.
Dr Jin: So well said, and I am sure you are being there at those moments where that patient and his family meant even more to them than it did to you. Dr Panzer in your role as the VP of care transformation, you were instrumental in developing this collaborative care team model at Heartland Health. Can you tell us a little bit more about how you came up with the model and how you implemented it?
Dr Panzer: Sure. We call the model advanced team-based care. And personally, I first learned of a, a model like this from Chris Sinsky at the AMA. About 10 years ago, I, I saw her speak at a conference about her practice in Iowa, where she works. And then later I had the privilege and opportunity to work at Iora Health, an organization that practices a similar model. And, and I was a medical director in Chicago for two years at one of their practices. So. when I was coming to Heartland and I've been here for about four and a half years, we were looking into taking a model like this and, and creating one of our sites, turning it into an innovation center, to have the space to create a new model. And we visited Bellin Health in Wisconsin, that practices a similar version of care. We adopted their title care team coordinator, and we created a plan in February of 2019.
We started practicing with this model and the way the model works for us is on the most basic level the care team coordinator is with the patient, for the intake portion of the visit. And then I, as a primary care provider and the other primary care providers will join for what we call the team visit where the patient, the care team coordinator, and the primary care provider, which are physicians and nurse practitioners in our model, after the team visit, we as primary care providers leave and the care team coordinator and the patient are together to do the end of the visit. And in order for this to happen, we have two-to-one ratio where there are two care team coordinators for every primary care provider while in clinic.
Dr Jin: Got it. I'm glad you brought up the two-to-one ratio. That is another key point that I wanted to highlight. So, while the team visit is happening with the one CTC and the provider and the patient, what is the other CTC doing?
Dr Panzer: While I'm working with one CTC in the room, the other CTC is rooming the next patient. And so, when I finish the team visit, I immediately complete my note, the CTC, who is in the note while I was in the room will send me the note. I will immediately finish the note, which often reminds me of things that we might have forgotten. Everything is done for that patient by the time they leave. And then I will move on to the next patient who has been prepped, their visit intake is already done. And then I move into the team visit with the second care team coordinator.
Dr Jin: So, it's all wonderfully efficient.
Dr Panzer: You know, it's interesting you say that. I read a quote about advanced team-based care in the past. And they said that it's like a dance and sometimes you step on each other's feet, but it's better than dancing alone. We all know in primary care that there's, there's a dance that happens between patients and physicians, where we are going through multiple different agenda items. And we have to be flexible because the needs of all of us as individuals sometimes varies. There could be new awareness of, of situations or illnesses or issues in the middle of a visit. So that flexibility is really important. The care team coordinator model allows us when we have two people in the room we're able to be even more flexible, but there's definitely a customizability to the model that makes it not always work perfectly. There's sometimes I leave the room and the next patient might not be ready or, or I might be the bottleneck and getting us too far behind, but overall, it's really phenomenal when it works well. And most of the times, it does work well.
Dr Jin: And I imagine just with time and experience working together, it's naturally fine-tuned and optimized. My two follow-up questions are one, how do you train these care team coordinators? And how long does it take? And two, in this era of staff shortages, how do you find enough care team coordinators who maintain the two-to-one ratio?
Dr Panzer: In terms of training, some of our CTCs were medical assistants before they were CTCs. Some had other health care experience. All of our CTCs go through a training and a competency on the basic elements of the MA portions of visits, such as point-of-care, testing, vital signs, immunizations, and some of the other needs of the clinic, such as autoclaving and EKGs, et cetera. In terms of the other pieces of the model that aren't in the traditional MA role, we have them do shadowing with existing CTCs. And then over the course of several months, I would say there's a learning curve where they are learning by being in the room with providers. They aren't expected on day one when they're first working by themselves or autonomously that they are able to do all the things that a CTC who has been working for one or two years is able to do.
Dr Jin: So, it's not so much a formal curriculum as just learning by shadowing on the go, on the job.
Dr Panzer: There is a short formal curriculum for the CTC-only portions of the, of the role, but the expectation is that they're going to practice and hone those skills in the real working environment and in alongside providers. So, I think one of the benefits across the country, a lot of the way we think about education is very formal. Like, go to school, be put in a learning environment, and learn. And part of what we're doing is, is more of an experiential learning. And so, we've had folks who are well-trained medical assistants who join and then say, wow, I've never learned so much as I've learned in these, these first six months on this role.
Deming: I really enjoyed that part of the training. It was a team effort on the part of the clinic in some ways. There was time set aside for me to shadow already established CTCs. So, they were teaching me the things that they had learned and then just built into my day was that time with the provider and the patient. So, so I was hearing more of like, what are the right questions to ask when someone says they're having headaches? What are some of the things I could set aside for the provider? So, they don't have to ask those. And then after the visit, the provider would tell me, oh, this is how you could have helped me in this way too. So, it was nice having many layers and at the moment when I would be doing it in the future. So, I'd remember it more in context.
Dr Jin: So how many days was the actual instructional part where it was, this is how you do team documentation, and this is how you put in orders versus the time that was spent shadowing?
Dr Panzer: We are currently training a, a few CTCs right now and they're training before they're independently in the room without somebody else is about six to eight weeks. And some of that is medical assistant training. And some of it is CTC training. And so, for at least two to three weeks of that, they are doing pieces of the CTC role with another CTC in the room, shadowing them. So, in that situation, there are three people in the room. I am in the room with two CTCs, one of which is helping the other one.
Dr Jin: Okay. And then just to go back to the second part, my question in terms of staffing shortages, are you facing challenges right now, recruiting CTCs?
Dr Panzer: So, we're facing challenges, recruiting medical assistants, for sure. We've partnered with an organization called NIMAA to do an in-house medical assistant training because of the more flexible nature of the CTC role and the way that we've posted the job description. We are able to attract other people from other aspects of health care. So, we have a CTC who is an EMT. We have CTCs actually that were trained as doctors in other countries that are studying and waiting to go to residency in the US for a few years. So, we're able to attract different types of candidates in different ways, which if you think has been helpful in recruiting and it doesn't take away from our pool of candidates at our other sites who are only able to hire medical assistants into their roles.
Dr Jin: And what's your outreach process for finding these other candidates?
Dr Panzer: We work with several schools in the region. We also work with a program called Upwardly Global that helps with some of the international candidates. At Heartland, our sort of specialty or our niche is to take care of immigrants, refugees, and patients with serious mental illness. So, we're specifically interested in, in having a multicultural, multilingual group of caretakers, caregivers, including our physicians, nurse practitioners, physician's assistants, and our care team coordinators and medical assistants. I think one thing that's really important with this model is, is how the provider acts in this model. So, I view myself really as a team leader. I enjoy developing strong personal relationships with my patients, but I also try really hard to make sure my care team coordinators also develop a strong relationship with patients. So, we work hard to try to make sure that the same CTC is seeing the same patient in with continuity and future visits.
I try to make sure that as I'm explaining something to my patient, my CTC is understanding it because I know when I step out of the room, they're going to get the questions that the patient in a model where there's not a CTC wouldn't ask anybody or would ask an MA who wasn't in the encounter and doesn't really understand as well. And so, I view it as my job to teach my CTCs and to make sure that I'm listening to them. I think one of the things that Erica and I have talked about in the past is in the medical assistant role, sometimes you do a bunch of work and the provider doesn't necessarily read your note or read your work and it feels like less motivating. So, I think it's really important to me to make sure that if they've gathered history and they've set an agenda that I pay attention to that, and I ask them questions and ask the patient questions and to make sure that that time is valued and, and valuable and, and only gets better over time. So, I think one thing that I learned at Iora, there was a saying there, our model changes everything. Will it change you? And I think that the change in a care model like this is really about us as primary care providers, allowing other people into the relationships with patients and into the core part of medical visits, which is agenda setting, history taking, et cetera.
Dr Jin: Yeah. Completely agree. And I think the fact that you use the term team visit is very telling and that in itself is hopefully a little bit culture changing because I agree it's the physician definitely needs to give up a level of control, which is very hard to do for physicians who are not used to that. Erica, any thoughts on how this team culture or from the physician's standpoint, how it can be optimized so that you do feel valued as a member of the team?
Deming: So, working as a medical assistant, I was lucky. I always had wonderful relationships with the providers and physicians that I was working with, but I feel like the models we were working within didn't incentivize us to communicate or share our information with one another. So, we would go maybe a whole morning. And like, all I would say to them is room two is ready or <laugh>, or we're running behind or something like that. And often we don't even sit by each other necessarily, like depending on if we prioritize teams being together and there were a lot of missed opportunities. I felt like as a medical assistant, when the patient was reaching out to me, or there's a lot of points of connection between patient and medical assistant, where they're starting to open up that once they get back to the room, they're telling them, this is what happened to me.
And it was awful, or these are the details you need to know. And then we often have to cut them off. But what I like about this model, is that you get to actually collect those nuggets of information, put 'em in a document that is useful to the provider. And then the provider or physician is then incentivized to look at it because we're actually doing the visit together. So, it's not just adding to their workflow that they have something else they have to do. There are moments when we're communicating and going over that. So, we're not asking the same thing over and over to the patient. And I think that that helps incentivize us as CTCs to want to get the best information because we know it's being utilized. So, I think in terms of how a physician could help care team coordinators feel a part of the team, it's when our work is used <laugh> and when we feel like we're contributing that I think builds that trust.
Dr Jin: I remember feeling that same way as a medical student, it was the same where all the information I collected was never actually read. So yeah, I think that's a great point.
Deming: Yeah. And then on the end of the visit side, too, when a patient, like you said, Jeff, asks the question and then I would have to tell them sincerely, I'm sorry. I don't know how long they wanted you to wear the boot for your plantar fasciitis I, I wasn't here and they're already with the next patient. So, it's nice that we're being trusted with information then too, to educate the patient on the next steps so they can actually follow through on the care too.
Dr Jin: And then you were saying, you know, afterwards, when the physician leaves and you're doing the discharge with the patient, oftentimes there's more stuff that comes up. And I guess sometimes the patient kind of gives some feedback about how the physicians, or how made them uncomfortable or any kind of communication or trust gaps that happened. How do you handle that?
Deming: I think that's where the flexibility came in and that's why it was so great that we had been working together on teams for a long time, because we knew our own workflows. And if Jeff would have time for an aside, right after a visit, or if it was a timely question, like they need to know this now, or this is something we should address immediately. I learned over time when it was best to bring that up. But I also felt empowered to address certain things on my own. I was remembering if I can share a story today, there was a patient that we had seen who during the team visit, Jeff had been talking with her about the grief that she was going through. She had lost a family member in the last year, and eventually, they got to talking about preventive care tests and she just hadn't gotten her mammogram and a couple other tests yet.
And so, I was next to him documenting and he was talking to the patient, and they were going through many different issues together. They were very important. And I just, as another set of ears in the room was listening to her saying, I just don't want to go to that hospital for the test. And I interpreted that as she didn't want to go there because she had a bad experience there, or she had had a loved one cared for there. And so, during the discharge, I asked her myself, do you want to be referred someplace else to a different hospital? And she said, yes, I would really love that. Thank you. And so, I was able to do that myself and I think this is what distinguishes the CTC role from a scribe as well is that you can work through those processes with the patient, you're clinical you're able to make those changes for them.
And then I went out of the room, and I explained to Jeff what we had done together and where we are at now with the preventive care test and we celebrated the win and then we're able to move on. So, I think it just depends on the time that you have and like what the importance level is for that moment.
Conversely, if it's something they need another appointment for it, we can help set that expectation for them that we can say, oh, let's actually make a visit for you sooner than we said, because then you can talk in detail with the doctor about your concern about X, Y, Z. And in that way, we would save time for the providers too, because they didn't have to go in and explain to them. We don't have time. Now we could talk later.
Dr Jin: That's a great example, Dr Panzer, any other tips you have on how to develop this productive and trusting relationship with the CTC or a medical assistant?
Dr Panzer: I have some thoughts. I also wanted to share just to piggyback on what Erica was just saying. I think that there's a difference between a scribe who is a clerical role to having like a clinical partner. And I think in that specific example that Erica just shared that patient's family member actually passed away at that hospital. And so, I didn't pick up on that. I think she was trying to say that, whereas Erica did. And so, I think those are really important factor for this patient. Physicians or nurse practitioners in the model where we are making the diagnostic decisions and, and treatment decisions. But so much of care is care coordination and making sure that they actually make it to their referral, for example. And so it, it's a true partnership. We in health care can learn from looking at the issue of trust more broadly.
I read a book “Five Dysfunctions of a Team” that really talks about trust and vulnerability as like the foundation to any team. And so, I've really adopted that, like how can I be vulnerable in front of others and get to know people on a deeper level? So, some of the things that I've always tried to do, I always try to go to lunch with anybody that I'm going to work closely with to get to know who they are as a person. I think that we socialize outside of work. I think it's really important, not just so that you can work together as a team, but it, it makes a better working environment, but then it has the added benefit of being able to question each other and be real with each other. And so, I think I'm able to give more feedback to my CTCs, knowing that they're not necessarily taking it personally and, and vice versa. I've had many people give me feedback about, you know, in that interaction, the patient even told me after you left, like, they didn't like the way you said this or that. And if they didn't feel some trust with me, I don't think they would've said that.
Deming: I think an important thing that helped us do that too, is that we sat next to each other during the day. And we had huddles in the morning and oftentimes before the afternoon session too, so were more opportunities to get to know each other and to talk through, oh, this is how the patients saw that visit. And in traditional models where you're not staying next to each other, you just don't have that chance or that familiarity when you're not near each other.
Dr Jin: True. Yeah. Co-location is so important and in the era of COVID, it became more difficult, but I agree. It is it's essential. And then one last point that I kind of just thought of was will patients feel comfortable sharing all their personal information with someone who is not their physician? Because traditionally old school medicine, it was the physician-patient bond, was so sacred, and then adding another care team member to that mix. There is some skepticism about that. I think most of us are beyond that now, but just in terms of your personal experience, have you ever found that to be an issue?
Deming: I was surprised how rarely patients requested that I step out actually, and I was encouraged to when we had new patients, especially explain that at our clinic, we had this different model where I would be part of the visit taking notes. And I would explain to them it's so that you and your doctor can speak a little bit more closely together. So, they're not on the computer while you're speaking with each other. And then when I explained that they were almost always kind of excited about it or like, oh yeah, sure, definitely be in the visit then. And then if they were a little on the fence, I would say, it's okay. You can just visit on your own. But many people, I just told them, okay, I'll be there. And if you change your mind, just let me know. I can always step out. But it was very rare that I had someone not want me there.
On the contrary, I found that our visits became just what we call them team visits, where we would room a patient. And for example, we roomed someone who six months earlier, we had helped him get nicotine patches and work on calling the quit line for smoking. And six months later, he came and saw me and told me that he was still not smoking. And we had this big celebration for the win. And then that was a big part of visit. And then we brought Jeff in and we all celebrated together again. And it just felt like, of course, I would be there for that. We're all doing this team visit together. And the more that they see me documenting next to him, the more that they consider me a part of the medical team where it's appropriate, that I should be there for the really sensitive parts of their care too.
Dr Jin: And it's another advocate for them. And another part of the team that's promoting their own health.
Dr Panzer: And I'll just add, I've been doing between working at Iora and working at Heartland on and off for six years, I've been doing this sort of model. It's definitely the vast minority of situations where a patient won't feel comfortable and, and would ask care team coordinator to step out of the room. Certainly, patients who have been seen over and over again will be more likely to recognize the benefit and want them to be there.
Dr Jin: Excellent. Any final thoughts from either of you that you want to share?
Dr Panzer: Yeah. I have one or two things we know in primary care that there's a lot of nuance to what we do. For example, a patient might be coming in for a follow up on, on their diabetes. And then they were hospitalized say a week ago. And all of a sudden that sort of planned visit is pretty different. And so, we as doctors know that we have to sort of shift priorities and change what we're focusing on during that visit. Oftentimes what I've found is, is in a traditional more traditional medical assistant model, they're still doing sort of the same intake process, no matter what the type of visit or if the visit has changed. And what we've encouraged is for the CTCs to use their judgment, use their wisdom. And so there are situations where Erica and others in a situation like that, where a patient was hospitalized, they spend the time trying to make sure that we get the record. Sometimes we don't know that they were hospitalized until they show up in our clinic. So, she will spend her time making sure we get those records rather than going through a standardized set of screening questions. And I think what's really important in that situation is for me to support her in using her judgment. Because if I were to say, oh, why didn't you, why did you miss these things? Then in the future she would be less likely to use her judgment. I think that's one of the nice things about having this overlap in the room is that we get to learn each other in our patterns and we get to trust each other. That certainly allows us to trust the CTCs and using their judgment more and more.
Dr Jin: Yeah. And so overall it sounds like the CTC program is a win for the physicians, the win for the medical assistants who are now elevated to the CTC role and a win for patients. So win, win, win.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
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