Connecting patients who have a chronic illness with the care they need to get their diabetes, hypertension or high blood pressure under control is already a major challenge for the U.S. health care system. But there is potential for the situation to get much worse if projected physician shortages come to pass.

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One possible way to mitigate this concern, however, is with the innovative use of  team-based care, with physician leaders coordinating focused multidisciplinary efforts involving primary care and specialty physicians, nonphysician clinical staff such as nurses and pharmacists, plus nonclinical staff.

Kimberly Herner, MD
Kimberly Herner, MD

AMA policy defines physician-led team-based health care as the consistent use by a physician of the leadership knowledge, skills and expertise necessary to identify, engage and elicit from each team member the unique set of training, experience and qualifications needed to help patients achieve their care goals, and to supervise the application of these skills.

AMA policy also recognizes “nonphysician providers as valuable components of the physician-led health care team.”

It may no longer be enough to say that this is the way care should be delivered, because it could become the way care must be delivered.

“I think one, because of the shortages we need to have a different way of doing business,” said Kimberly Herner, MD. “And two, it's better for the patient, because they're getting the right care from the right person.”

Dr. Herner is the chief quality officer for Valley Medical Center, which is part of UW Medicine, the University of Washington health system.

“It is unfortunate that there likely will be a physician shortage, so we're going to have to do things differently if we want to help our patients stay healthy and manage their health issues,” said Dr. Herner, who describes herself as a “big proponent” of team-based care (PDF).

“I'm a family physician by background, so I'm also a big proponent of prevention and trying to help people stay healthy,” she said.

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The U.S. faces a projected shortage of between 37,800 and 124,000 physicians within 12 years, according to The Complexities of Physician Supply and Demand: Projections From 2019 to 2034 (PDF), a report released by the Association of American Medical Colleges.

This includes a shortage of between 17,800 and 48,000 primary care physicians by 2034.

“I'm biased, as I feel that everyone should have a primary care physician, but there's not enough to go around, so how can we extend their capacity?” Dr. Herner said. “Having a team means I don't have to see everybody every time. I could have them see my team members sometimes.”

After a clinical encounter in which she didn’t participate, Dr. Herner can check in with colleagues to learn about the patient, either through the EHR, phone or an in-person meeting.

A physician now for three decades, including 27 with Valley Medical Center, Dr. Herner said these touch points with physician and nonphysician colleagues have restored some of the collegiality that used to be more present in the profession.

“It's more fun and you’re not alone, because things can be hard, so it's good to be able to have that support system,” Dr. Herner said. “By creating these multidisciplinary teams, as well as having these forums to have conversations about care, it allows for a little more collegiality, and I think it allows for a little more joy in work.”

The trend for more collaboration and breaking down silos began around ten to 15 years ago, she said, and has accelerated in the past five. This has extended beyond the clinic- or office-based physicians and staff she sees every day and now extends into collaboration with urgent care, the emergency department and to hospitalists.

“In the last five years, I think this culture has really started to come together,” Dr. Herner said. “There’s a lot more of a ‘we’re-all-in-this-together’ type of mentality.”

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In addition to stellar patient outcomes and more staff satisfaction, Valley Medical Center facilities are perennially recognized as gold-level performers in the Target: BP™ program, a national initiative co-led by the AMA and American Heart Association.

The Target: BP Recognition Program celebrates physician practices and health systems who treat patients with hypertension, for their commitment to BP control within the populations they serve. For those achieving high rates of BP control in their patient populations, these physician practices and health systems are helping to reduce the number of Americans who suffer from heart attacks and strokes.

Valley Medical Center’s Clinic Network also earned gold-level status in another American Heart Association program for cholesterol control, and its primary care clinics earned recognition for excellence in diabetes control and patient-centered medical home from the National Committee for Quality Assurance.

About one in 10 Americans has diabetes, the majority of whom have type 2 diabetes, and about 20% are unaware of that fact. Also, more than one in three adults in our nation has prediabetes—and more than 80% of them don’t know it. Add the potential risk of COVID-19 infection to this situation, and it is starkly evident that screening for prediabetes and type 2 diabetes is more important than ever, especially for patients 35 to 70 with overweight or obesity.

The AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies. This comprehensive and customized approach helps clinical practices and health care organizations identify people with prediabetes and manage the risk of developing type 2 diabetes, including referring people at risk to a National DPP lifestyle-change program based on their individual needs.

High cholesterol is a common health condition in the United States. In fact, nearly 94 million adults over the age of 20 have what could be considered borderline high cholesterol, according to the Centers for Disease Control and Prevention.

As part of the AMA Accelerating Change in Medical Education  Consortium, the Chronic Disease Prevention and Management (CDPM) interest group was formed—a team of medical educators dedicated to improving CDPM in medical education and practice by drawing on health systems science—the “third pillar” of medical education.

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According to Dr. Herner, Valley Medical Center’s success with team-based care can be attributed to:

  • Patient education and engagement.
  • Risk stratification of patients.
  • Creating care pathways with well-defined roles for each member of the team.

The new diabetes care pathway includes having a registered nurse calling the newly diagnosed patient and saying, “Let’s talk about what this means and set you up for an appointment,” Dr. Herner explained.

“We tried doing a whole big education piece with that first call and people were overwhelmed—information overload,” she added.

A similar approach is taken with patients being discharged from the hospital. While Dr. Herner said the hospital staff does an “awesome job” at medication reconciliation, patients are just anxious to get home and may not be fully paying attention. Having a call from an ambulatory nurse within 24 to 72 hours after discharge has been very effective.

“Having that connection with the clinic nurse within a couple days really helps to solidify that they're on the right medication and that they understand the care plan,” she explained.

Teaching patients the importance of checking their weight, oxygen saturation, blood sugar or blood pressure and how to measure their levels has also helped prevent readmissions and emergency department visits.

For patients with diabetes, risk stratification helps direct them to the right physician.

“We really looked at how do we clarify the role of the primary care physician versus the endocrinologist, so that we can make sure that each person's expertise is being used appropriately,” Dr. Herner said. “We created a pathway where, if certain conditions exist, we consider referral to an endocrinologist. Then, once these conditions are addressed, we send them back to their regular doctor.”

Medical assistants and nurses also check patients’ records for gaps in care before they visit so physicians don’t have to.

“Every time you can decrease the click count in the EHR, it really does help decrease the work of the physician so they can spend that time engaging with the patient,” Dr. Herner said, adding that, by standardizing routine care, patients with more complex needs can receive more personalized care.

She noted that the work groups that create the pathways always include a primary care and specialist “champion” who review the evidence and agree on best practices following the Institute of Medicine’s six domains of health care quality:

  • Safety.
  • Effectiveness.
  • Patient-centeredness.
  • Timeliness.
  • Efficiency.
  • Equity.

Data analytics are reviewed to ensure that pathways are followed and that they improve outcomes.

“If we're following the pathway, ideally, the assumption is that our patients are getting better,” Dr. Herner said. “If our outcomes aren't what we expect, we go back and do process improvement to figure out how do we do things differently to have better outcomes for our patients.”

In addition to physicians and nurses, care teams can include clinical pharmacists, dieticians, physical therapists and nonclinical health coaches and facilitators who use motivational interviewing and often the findhelp website that has been integrated into the Valley Medical Center EHR to connect patients with resources to address social determinants of health needs such as transportation and food or housing insecurity.

“The case management on the acute side addresses what's happening with the episode of care when they're in the hospital,” Dr. Herner said. “On the ambulatory side, the care-management team  is focused on more longitudinal care, it involves building relationships with patients and helping them live their healthiest lives.”

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