In the summer of 2016, Stanford Health Care’s primary care clinic in Santa Clara launched Primary Care 2.0, a team-based primary care model developed by researchers at Stanford Medicine. The goal was to tackle an epidemic of physician burnout by transforming health care delivery from the traditional physician-centered model to a team-centered model.
Instead of taking care of most of the patient caseload themselves, the clinic’s doctors work closely with members of a team of medical providers, including nurses, pharmacists, and dietitians.
More than five years later, the 2.0 primary care model has proven to be beneficial for both patients and primary care physicians, but only if the model is sustained, according to a recent study by researchers at Stanford Medicine.
“It turns out doctors are very resilient, but if their practice isn’t serving them it might seem impossible,” said Megan Mahoney, MD, chief of staff at Stanford Health Care who also led the design and implementation. implementation of the model of care. “Stanford Medicine presented primary care 2.0 as an ideal model for team-based care with the explicit intention of solving this problem. “
The quadruple objective
Primary Care 2.0 is driven by a healthcare industry goal known as the Quadruple Goal, which is to improve the quality of care, cost savings, patient experience, and physician well-being. and staff. Quadruple goal is an extension of triple goal, which incorporated only the first three goals.
“Many of us have spoken about the problem of burnout and the lack of joy in practice in many primary care practices,” said Thomas Bodenheimer, MD, professor of family medicine at the University of California. San Francisco and one of the doctors who developed the Quadruple Lens.
For their research, Mahoney and his colleagues wanted to see if Model 2.0 helped prevent physician burnout. They interviewed 188 staff and clinicians at the Santa Clara clinic and four other Stanford clinics who were not using the new team-based model. Individuals were surveyed before the launch of Primary Care 2.0 and then nine, 15 and 24 months after its implementation.
The assessment showed that expanding the roles of medical assistants, increasing their ratio, and adding non-physician specialists, such as pharmacists and dieticians, significantly improved team development, according to the team. ‘study, published on September 19 in the Annals of Family Medicine. Jonathan Shaw, MD, clinical associate professor of primary care and population health at Stanford, is the lead author. Mahoney is the lead author.
Team development related to reducing burnout
In the researchers’ analysis, team development was significantly and inversely associated with burnout.
The researchers also found that the quality of care and patient satisfaction levels at the Santa Clara clinic remained similar to those at the control sites. Additionally, the labor cost per visit to the 2.0 primary care site was lower than at other clinics, and those costs declined over the four years after the model was launched.
The increased use of advanced practice clinicians, i.e. nurse practitioners and medical assistants in place of physicians, offset the additional cost of increased physician assistant staff and larger medical team.
Collective gains, however, did not translate into a sustained and statistically significant reduction in burnout. At nine and 15 months, less burnout was observed, but not at 24 months.
The change was likely the result of 16-month budget cuts that dropped the ratio of physician assistants to physicians from 2: 1 to 1.5: 1, Mahoney said. When medical assistants ran out of time for assigned tasks under Model 2.0, those tasks fell to physicians.
The researchers hypothesize that maintaining the original staffing levels of the intervention would have led to continued reductions in burnout. Without support, doctors at these clinics often take care of administrative tasks, such as filling out paperwork and dealing with insurance companies, in addition to seeing large numbers of patients, said Bodenheimer and others.
Burnout and results
Burnout is also hurting the bottom line of healthcare organizations, Shaw said. “Lower professional accomplishment is directly related to higher revenue, which adds the direct cost of replacing the clinician,” he said.
A series of studies by Stanford faculty have shown that burnout decreases the clinical productivity of physicians, increases revenue, and costs U.S. healthcare organizations $ 5 billion a year.
“Physician burnout has a substantial impact on access as well as the cost and quality of medical care,” said Tait Shanafelt, MD, Stanford Medicine wellness manager and Jeanie and Stew Richie professor.
Team-based models of care that tackle the root causes of burnout – excessive workload, inefficiency, and problems in the work environment – are key to reducing the physician burnout epidemic, a- he declared.
Primary Care 2.0 is designed for this, in part by expanding the role of the medical assistant, which is typically limited to taking patients to examination rooms and checking their vital signs. In Model 2.0, the ratio of medical assistants to physicians fell from the norm 1 (or less) to 1 to 2: 1.
The increased ratio allows physicians to have more in-depth and focused conversations during patient visits, while their physician assistants take clinical notes and are better informed about the patient’s health and care plan so they can address concerns follow-up patients.
Model 2.0 also includes more specialists on site, such as a clinical pharmacist who coordinates medications; a dietitian who provides nutritional assessments and advice on conditions such as diabetes; a physiotherapist who offers individualized care; and a behavioral health clinician who addresses the psychological concerns of patients and the social determinants of health.
“Some patients really need a multidisciplinary approach”
The model is particularly useful for patients with multiple medical or social problems. Once a week, the entire healthcare team discusses patients who are struggling to manage their health, a practice Korina De Bruyne, MD, clinical assistant professor of medicine and physician at the Santa Clara clinic, said she found. useful.
“Some patients really need a multidisciplinary approach,” said De Bruyne. “It was very helpful to have all of this under one roof, which took the load off the doctor and allowed us to divide and conquer.”
Additionally, Mahoney said, doctors who are not exhausted have more energy to nurture strong relationships with patients, which has been shown to improve their health.
The COVID-19 pandemic, Mahoney said, has exacerbated physician burnout, making it more vital than ever to shift Stanford’s primary care clinics to a team-based model of care.
Data from Stanford clinics shows the number of patient portal posts increased 38.5% from March 2020 to March 2021, putting additional pressure on primary care physicians on the front line of patient care, a Mahoney explained.
“When patients are scared, when they are nervous, when they have questions about COVID testing, all of those questions are directed to this primary care physician through a patient portal message,” she said, noting that ‘At the Santa Clara clinic, physician assistants could deliver about 30% of these messages, reducing the burden on physicians.
Starting in 2018, Mahoney and his colleagues began rolling out Primary Care 2.0 components to Stanford’s other four clinics, and they plan to continue implementing them across Stanford’s healthcare system.
“The Primary Care 2.0 initiative is precisely the type of systems thinking needed to reduce burnout and promote the well-being of clinicians,” said Shanafelt. “Adapting this approach to other specialties and extending it to Stanford Medicine will have a tremendous impact on the professional growth of our faculty and staff and serve as a model for other health systems to emulate. “
The other co-authors of the study at Stanford are Marcy Winget, PhD, director of the Stanford Medicine Evaluation Science Unit and Clinical Associate Professor of Primary Care and Population Health; qualitative researcher Cati Brown-Johnson, PhD; Timothy Seay-Morrison, executive director of outpatient and care lines at Stanford Health Care; biostatistician Donn Garvert; Marcie Levine, MD, clinical assistant professor in primary care and population health; and former Stanford Medicine research consultant Nadia Safaeinili.
The project was funded by Stanford Health Care.
Click on this video link to learn more about Primary Care 2.0.