In this episode of the AMA STEPS Forward® podcast, hear from physician expert Kevin D. Hopkins, MD, medical director at Cleveland Clinic, on how the advanced team-based care model yielded positive patient and practice outcomes. For a step-by-step guide on team-based care, review the AMA STEPS Forward® toolkit.
- Kevin D. Hopkins, MD, medical director, Cleveland Clinic; senior physician advisor, American Medical Association
- Christine Sinsky, MD, vice president of practice transformation, American Medical Association
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.
Dr. Sinsky: Well, hello. It's my pleasure to introduce to you today Dr. Kevin Hopkins, who is the primary care medical director at Cleveland Clinic. He is also a senior physician advisor to our work at the AMA in terms of professional satisfaction and practice transformation. Today Dr. Hopkins will be speaking with us about advanced team-based care with in-room support. Dr. Hopkins is a family physician, he has been a pioneer in this new model, and he will tell us his experience with the model and some of the data that he has accumulated with his experience. So welcome, Dr. Hopkins, off to you.
Dr. Hopkins: Thank you, Dr. Sinsky, it's a pleasure. Thank you for having me and inviting me today. So, I've been fortunate enough to work in an advanced team-based care model for nearly a decade now. And so my intent today is to sort of give a high-level overview of what that means. What is an advanced team-based care model? What are the nuts and bolts and practical points that I can share relative to what the workflow looks like, what patient flow looks like, that is slightly different from traditional in-office visit practice, and then what are some of the outcomes that we've realized and recognized as benefits of this team-based care model? That's my intent of what I hope to convey to you today.
So, the way that we define team-based care is a higher efficiency practice model. It's really designed to have multiple advantages, not only to patients and caregivers, but to a health care system as well. Our intent is to improve access for our patients so that our patients can access high quality care when and where they choose. As I mentioned, we want to improve quality of patient care and have better outcomes for our patients, for their health. We want to improve patient throughput by really looking at opportunities for efficiency in flow and in process design and application. We also have the intent to improve satisfaction really at all levels, not just patients, but certainly patient satisfaction is a high priority for us. But also to improve physician, nurse practitioner, physician assistant, clinical caregiver, and clerical caregiver, satisfaction and engagement in the care process as well.
A team-based care model utilizes a team approach in caring for patients, as the name implies. We recognize that to provide care for patients today that is high quality and lower cost and achieves great outcomes and meets expectations relative to patient and caregiver experience, it's really too much to be done by any one person. And so, we need a team to share that load and to shoulder the responsibility. Responsibility for care is delegated and shared among multiple caregivers who are part of a team. Each individual in the chain of patient care functions to the highest level of their qualification or certification. In short, physicians do what they are uniquely trained and qualified to do while all other lesser tasks are delegated to someone else in the care team.
So, what does it look like in practicality? What's the office visit workflow? We'll start with a comparison to a traditional office model. When it comes to ambulatory office visits, whether you're talking about in-office traditional visits, or certainly now that we're engaged in more virtual care, have multiple components, but there's three basic buckets into which our work falls. There's visit prep or pre-visit work, post-visit work, what happens after the encounter, and then what happens during the actual visit. Inside the actual visit, again, whether virtual or in office, there are four defined stages: data gathering, physical exam and synthesis of that data, medical decision-making, patient education, and plan of care implementation. As I mentioned, traditionally, all of these buckets of work or steps in the process have been thought to be the responsibility of the clinician themselves, the physician. We've historically had that doctor-does-it-all mentality. The way health care is today, with all the changes we've experienced, and certainly as a result of further implementation and embracing digital health platforms and virtual care, we can no longer afford to pretend that physicians can adequately do all this work by themselves. The work must be distributed to people who are trained, capable and confident in their abilities to provide care.
So, what happens in an advanced team-based care model? A lot of the pre-visit work, things that happen prior to the actual appointment, are able to be successfully delegated to a medical assistant or other clinical assistant, such as an RN or an LPN who might be serving in that type of clinical assistant role. These tasks include things like pre-visit planning and lab ordering or pending orders for future visits and beginning to plan the next encounter, printing any data that might be necessary to provide in paper form. In our system we print what's called a snapshot from our EMR, which includes the patient name and demographics. It also includes their medication list, current active problem list, and a review of their health maintenance and overdue health maintenance topics or things that are coming undo. That allows the clinician to reference that during the encounter.
I also have my medical assistants print the most recent labs if a patient's coming in for chronic condition follow up and I may have them do the last few sets of labs for comparisons that I can review that in real time with the patient. We also have the expectation that the clinical assistant will review the last office visit in our practice to see what was done, what changes may have been made, what was ordered and what may or may not have taken place since the last visit, as well as any specialty appointments, tests that were done by other providers, those types of things. So that by the time we go into the room, we’re up to date on the most recent developments with our patients. As far as the actual in-office visits or virtual visits, even, the medical assistant takes on a lot of other responsibilities and tasks.
Certainly, we do the traditional rooming intake, whether that's asking the intake questions that are either required by our health system or other regulatory agencies, asking about the chief complaint, reviewing patient's allergies and medications. We also ask them to tee up refills for any medications that are coming up on being due. We also ask them when they're doing that to try to align medication refills and prescriptions so that we have that synchronized bundled renewal, making sure that all chronic medications that a patient's on are renewed at the same time once a year, so that we keep those prescriptions aligned. We also have our medical assistants review the health maintenance for that patient, and even have initial discussions and penned orders for health maintenance topics that they may be due for, such as colorectal cancer screening or mammography. Certainly, they take and record the patient's vital signs.
In addition, once they're eliciting the chief complaint they start some documentation in the progress notes section of the EHR. Our medical assistants are vital at helping to set an agenda for the visit. As we all know, patients come in with their agenda for an appointment, and we have our agenda as well of things we wish to accomplish all in a relatively short period of time. So, we want to make sure we get on the same page. As the medical assistant asks some questions they begin documenting as I mentioned in the progress notes section of the EHR, asking questions relative to the history of present illness, any new complaints or questions relative to chronic health condition follow up. They then record this data in the progress notes section based on note templates that have been co-developed and co-maintained among the team so that they know what questions to ask when and how and where to document that best.
We also include a review of systems based on the note template that's utilized and have the medical assistant ask those preliminary questions. They may also administer pre-ordered vaccines if a patient's due for say a pneumonia vax or an influenza vaccine, and we've already approved the order for that. It can actually be delivered to the patient prior to the physician even entering the exam room. We also ask them to consider things like point-of-care testing, if patient's coming in for urinary symptoms, they may want to go ahead and get a urine sample. If a patient's coming in for chest pain or palpitations, in addition to alerting the clinic, the rest of the clinical team may go ahead and do an EKG based on our current and normal practices. And then once they've completed the rooming intake, then they present the patient much like a medical student or resident would to the attending physician so that we can move on throughout their visit.
So, it's a lot of work, we all understand that, but certainly medical assistants, RNs, LPNs, who are trained to do this are perfectly capable of accomplishing it and doing it well. So, what does that leave for the physician to do during the course of the office visit? Well, what we do is come into the room with our medical assistants. The medical assistant sits at the computer and now sort of takes on the role of scribe of that visit. So, they are in the room to help with documentation support. But the physician then confirms the history that has been pre-collected by the medical assistant, now taking ownership and responsibility for that history. We also perform the pertinent physical exam, complete the medical decision-making, articulate the plan, both for the benefit of the patient and also for our medical assistants, so that they can begin to pen orders based on what we articulate as the plan of care.
Then the physician has responsibility for ultimately filing those orders, whether it's for a test, a referral or even a medication refill or a new medication start. We also then put in the charge entry for the encounter for that day. By having help with in-room documentation support, it allows me to remain 100% focused on the patient rather than fumbling with a computer or looking for data. I allow my medical assistant to do that so that I can maintain eye contact and be totally engaged with the patient in the moment. That then allows me to exit the exam room and move on to other work, while my medical assistant remains in the room to wrap up the visit.
Throughout the visit, as I mentioned, the medical assistant remains in the room with me as the physician functioning as a scribe, essentially, they implement the plan that I've articulated by pending orders. They update the problem list as needed. They provide educational resources based on links that we may provide to patients through the patient-facing electronic portal or in printed form. They also complete forms, letters, other documents that need to be filled out for the physician's signature, they'll even schedule a follow up visit in the exam room. And that's a huge patient satisfier. It also gives some measure of support over the clinical schedule to our clinical staff who know our patients best. The medical assistant then really completes and wraps up the visit by delivering the after visit summary to the patient, including their instructions, makes sure that the patient understands what's going on and what the next steps are and completes the visit then gives a warm handoff of that patient to the next team member, which may be a clerical team member, or they may actually discharge the patient from the office setting.
The medical assistants also do charge entry for the work that they completed, which is also important. After the visit and in between visits, the medical assistants assist with documentation of the assessment and plan of the note, they may follow up on test result status and make sure that a patient completed, for instance, their fecal or blood testing, that we may have sent them home with that day or lab tests that were ordered. Then they also look ahead at scheduled patients coming up in the next few days or next few weeks to make sure that any pre-work for that patient was done ahead of time.
So, I want to pivot now from talking about the process of advanced team-based care to outcomes. What did we see as a result of putting this type of model into play? My practice converted to a team-based care model in the second quarter of 2011, as I mentioned at the top of our visit today, nearly a decade ago. Some of the data that I have is relative to that time period, because it shows you the transition from our traditional model of care to an advanced team-based care model and what we experienced as a result of that transition. This bar graph shows productivity in terms of actual office visits or patients seen per month. And this is for May 2011 through August 2012. As I said, we went live with team-based care in second quarter 2011. So, our baseline was a hundred slots per week of scheduled patient visits or 400 per month. Over the course of this time period of slightly more than a year, we realized an average of 102 additional patient visits per month above and beyond what our previous baseline template had been. This is nearly equivalent to an additional full week of productivity each month, based on just the visit volume.
This is a similar set of data expressed in RVUs, relative value units, for 2010, 2011 and 2012. The red line is 2010 data from my own practice by month. The yellow line is 2011 and the green is partial 2012 data. As you can see, when we initiated team-based care in quarter two of 2011, that's where you start to see the yellow and red lines begin to diverge. And the increased volume of visits that I mentioned in the previous slide translated to certainly a recognized and realized increase volume of RVUs, which then led to increase in collections and revenue as a result. I also want to share with you that regardless of what type of payment model or contract you may be involved in for care for patients, an advanced team-based care model makes sense not only from a practicality and caregiver burnout prevention and mitigation standpoint but also as I mentioned from a quality of care and a value-based care perspective by improving the quality of care while decreasing the overall cost of care. What this graph shows is our anecdotal evidence of the relationship that seemingly exists between access or primary care practice encounters and hospitalization or hospital admission utilization.
And that, there seems to be an inversely proportional relationship that the more frequently our patients in primary care access our services, whether it's through a virtual encounter or in-office encounter, the less likely they are to utilize inpatient and observational hospital resources. So, when you're thinking about value-based care, it certainly affects the cost curve for the care that we deliver. And so advanced team-based care in a lot of ways makes sense, regardless of what payment model you may be a part of. I want to share with you a little bit about our patient experience and quality metrics outcomes as well. This shows quarter two 2011 data compared to quarter two 2012 data in my own practice for some patient experience outcomes. You'll see that we appreciated significant improvements in our patient experience scores during the time of implementation of our advanced team-based care model.
One that stands out, so, I've placed a circle on here, is the question about the time that the clinician or clinical provider spent with the patient. On average, I probably spend the same amount, or even a little less time, in an exam room with a patient now, but the perception is that it's more because it's higher quality, better quality time because I'm focused on the patient rather than focused on a computer screen. So, you'll see that our patients score us, and this trend has continued to this day, much higher in this category than they did previously. Some quality indicators that we chose to track during the time of conversion are included here.
And you'll see that all of them saw some, even though they may be modest gains or improvements in our performance, some of this is around just documentation. So for instance, another thing that we track that's not on here is patients with coronary disease or diabetes who are on daily aspirin. A lot of our patients were taking it because I had asked them to or recommended it. But a lot of times I'd failed to document it in the EMR. As we all know, if it wasn't documented it wasn't done. So, some of that was just improvement in documentation quality and thoroughness because I was having somebody else do it instead of me trying to do it all.
One thing I want to address before we wrap up today, and that is the use of medical assistants or other para-health professionals in helping to document and complete an ambulatory visit. So sometimes there's some confusion around this, around who can do what and whose job is what. We were fortunate enough because of our relationship with the AMA and Dr. Sinsky to host representatives from The Joint Commission for a learning visit in March of 2017. They were very interested in seeing our model and seeing what it looked like and who did what and how it added to efficiency and the patient experience and better outcomes, as well as the caregiver experience.
We had nothing but positive feedback. They were excited about what we were doing and thought that this should be part of the gold standard model for care at other institutions and other offices going forward. A lot of our regulatory, regulations have been written now years ago, or even more than a decade ago and are not completely relevant to current practice setting and environment. So as our federal and state and local agencies seek to update their documentation and guidance, they want to learn from what we're doing at the cutting edge of health care delivery. It was a privilege to host representatives from The Joint Commission, and we certainly learned a lot from the process as well. That's what I have to share with you today. It's a high-level overview of team-based care with in-room documentation support and what our experience has been as we implemented this practice now nearly ten years ago.
Dr. Sinsky: Excellent, Kevin, thanks so much for sharing that. I do have a few questions that I'd like to discuss with you. And so let's move into that portion of your presentation. And let's take them almost in reverse order to when they came up, because the last question I had had to do with the Joint Commission visit. And so, and this is more of a comment than a question. So, I want to thank you for hosting The Joint Commission. Also tell you that we hosted them as well, your practice and my own practice in Iowa were the two practices that The Joint Commission visited. And it was very important for them to do that because they clarified something that has been a barrier for many people for sharing tasks and delegating work to upskilled team members.
And they clarified that, in fact, other clinical assistance could pen the orders and could be documenting some portions of the note. And so, I want to direct the audience's attention to the fact that at the AMA now we have a page on our website called Debunking Regulatory Myths, and we identify the myth, and then we go to the source, in this case the standard setter of The Joint Commission, to debunk that myth. We also have myths that come out of federal payment policies from CMS, and we debunk those myths and then point to the place in the federal register, where that information s made more clear. So again, that was more of a comment, but anything else you want to say to that, The Joint Commission or to regulation Kevin, before we move on.
Dr. Hopkins: I'll just add that your work and the AMA team’s work on that has been vitally important. And I've learned from you, Chris, that when someone says, well, we can't do that because of regulatory requirements to always ask, can you show me the regulatory requirement? Can you show me where that comes from? Because oftentimes people don't know how to answer that question because it's just been something we've always done in the way we've always done it. And a lot of the restrictions that we place on things like scope of practice and those types of things, they're for people's safety and for our good, but oftentimes it's self-imposed restrictions within our organization. And so, we sort of handcuff ourselves, and lose some efficiency as a result. Certainly, we don't want to jeopardize patient or caregiver safety, but we also want to practice in the way that is most efficient and makes the most sense. So, thank you for your work in that.
Dr. Sinsky: Well, thank you. So, and as you know, just to carry on to that, we hosted a compliance summit in June or July of of 2020, and brought in compliance professionals from across the country. You presented your model to that group, and one of the most memorable statements that I heard from a compliance professional was we have to become the people of yes, and not always be the people of no. And we know that that's what often happens out of an abundance of caution. There may be a federal standard or regulation at the federal level, then it becomes over interpreted at the local level. And so becoming the people of yes or debunking the regulatory myths, I think is one of the ways that we can remove some of the barriers to advanced models of team-based care.
So, my second question for your area for further comment has to do with the comments you were making about undivided attention, and it made me realize that I believe when physicians give our undivided attention to our patients, that that is one of our most powerful diagnostic and therapeutic tools. That we are better diagnosticians when we are not multitasking or having those attentional blinks, where we miss cues. So I wonder if there's anything more you want to talk about, about your own experience of feeling like a better doctor because of that undivided attention, that more powerful diagnostic tool that you offer your patients.
Dr. Hopkins: Yes, we've probably all experienced the importance and the value of being present in the moment. And certainly, that is valuable for our patients and the relationships we have with our patients. It's also valuable for our personal relationships, right? I know when I'm not exactly present, I'm not as good of a husband, I'm not as good of a father. And those are relationships that are vitally important to me. So, I need to be present in the moment, and patients find value in that. I think if I'm not present in the moment, if I'm distracted by fumbling with a computer or trying to do data entry work, I'm missing out on potential things like body language, non-verbal communication and what my patient may be telling me with their body and their face, that their words are giving me a different message. So I think that is vitally important, that we are completely 100% present, actively engaged with our patients.
Speaker: Great. And then the last area that I'd like to expand on just a little bit was the, the actual model itself and the spectrum of skill levels among the potential assistants. I think many people confuse scribing and advanced team-based models of care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.