Teamwork and the patient-centered medical home

When delivering comprehensive quality care, everyone who interacts with patients, from the time they enter the facility to the time they leave, must work as a cooperative member of the healthcare team. When managers are asked to name the most important attributes for medical professionals, teamwork is the highest on the list.

Teamwork

Although we would all enjoy working in an office where everyone gets along and likes everyone, this does not always happen. Personal feelings must be set aside at work, and all employees must cooperate with others to get the job done efficiently. If a medical assistant has an issue with another employee, the first move would be to discuss it privately with the other person. If the situation does not improve, perhaps a supervisor (office or practice manager) should be involved for further action. A medical assistant should never bring the provider into the discussion unless there is no supervisor or office manager available.

Staff members must work together for the good of the patients and practice. They must be willing to perform duties outside a formal job description if they are needed in other areas of the office. Many supervisors frown on employees who state, “That’s not in my job description.”

A professional medical assistant should perform the duty and later discuss with the supervisor any valid reasons that the task should have been assigned to someone else. However, if the task is illegal, unethical, or places the patient or anyone else in danger, it should not be done. If you are ever concerned about patient safety, you should discuss the situation with your supervisor before performing the task. Keep in mind that what tasks a medical assistant may be delegated to perform is set by each state’s medical practice act and board guidance, not by a single national rule.

Patient-centered medical home

The patient-centered medical home (PCMH) is a model of patient care that can help facilitate the population health process. In this model, patient care is looked at from a holistic approach. The healthcare team wants to be able to assist that patient with any issues that come up about his or her care. There would also be a nurse who coordinates all of the care for the patient, including issues about home healthcare, financial issues, transportation issues, etc.

Many models include a clinical pharmacist who is available to discuss medication questions and concerns with the patient.

The concept of population health has become a valuable piece of providing healthcare. The Centers for Disease Control and Prevention (CDC) describes population health as “an interdisciplinary customizable approach that allows departments to connect practice to policy for change to happen locally.” Many healthcare organizations look at population health as focused on their own patient population and what can be done to provide the best possible care.

The healthcare team will meet with the patient and their family to determine what their needs are. This meeting could be face-to-face or in a virtual format utilizing the patient portal or another virtual meeting platform like Zoom. There may also be a home visit to better assess the needs of the patient.

The Agency for Healthcare Research and Quality (AHRQ), which is a part of the Department of Health and Human Services (HHS), believes that improving our primary care system is the key to achieving high-quality, accessible, efficient healthcare for all Americans. The agency recognizes that health information technology (IT) plays a central role in the successful implementation of the key features of the primary care medical home. According to the AHRQ, the PCMH has five core functions and attributes:

1. Comprehensive care. The primary care practice has the potential to provide physical and mental healthcare, prevention and wellness, acute care, and chronic care to all patients of the practice. However, comprehensive care cannot be provided by only the practicing physician. It requires a team of care providers. The healthcare team includes physicians, nurse practitioners, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and medical assistants. If these specialty individuals are not readily available to smaller physician practices, virtual teams can be created online to link providers and patients to services in their communities.

2. Patient-centered care. The PCMH provides primary health care that is holistic and relationship based, always considering the individual patient and all facets of his or her life. However, establishing a partnership with patients and their families requires understanding and respect for each patient’s unique needs, culture, values, and preferences. Medical assistants are trained to provide respectful patient care regardless of individual patient factors. Within the PCMH, the medical assistant most directly contributes to patient-centered care by supporting care coordination, providing patient education and coaching, and facilitating patients’ access to and communication with the rest of the care team. The goal of the PCMH is to encourage and support patients in learning how to manage and organize their own care. Patients and families are recognized as core members of the care team.

3. Coordinated care. The PCMH coordinates care across all parts of the healthcare system, including specialty care, hospitals, home healthcare, and community services. Coordination is especially important when patients are transitioning from one site of care to another, such as from the hospital to home. The PCMH works at creating and maintaining open communication among patients and families, the medical home, and members of the broader healthcare team.

4. Quality and safety. The PCMH is committed to delivering quality healthcare by providing evidence-based medicine and shared decision-making with patients and families, assessing practice performance and working on improvements, collecting safety data, and measuring and responding to patients’ experiences and satisfaction. All of this information is made public to allow an open assessment of the practice and suggestions for possible methods of improvement.

5. Accessible services. The PCMH is designed to deliver accessible care. This is achieved by establishing policies that create shorter wait times for urgent needs, expanded office hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication, such as email and telephone care.

The goal of the PCMH is to improve patient outcomes and reduce costs. To be recognized as a PCMH, a healthcare facility must complete an accreditation process through a recognizing body, such as the National Committee for Quality Assurance (NCQA) PCMH Recognition program, The Joint Commission, or the Accreditation Association for Ambulatory Health Care (AAAHC). For further information about the PCMH model, refer to the AHRQ PCMH Resource Center.

Collaborative care

Collaborative care, also called integrated behavioral health care, brings medical and behavioral health clinicians together as one team – usually within the primary care office – working toward one set of health goals for the whole person, rather than treating mental and physical health as separate concerns. The terms integrated behavioral health care, behavioral health integration, integrated care, collaborative care, and primary care behavioral health are often used interchangeably to describe this approach.

The most widely used version of this approach, the collaborative care model (CoCM), relies on a small core team. The primary care provider leads the team and makes the overall treatment decisions. The behavioral health care manager follows the patient’s progress closely, coordinating care between visits and providing brief behavioral interventions. The psychiatric consultant advises the team on diagnosis and on medication or treatment changes, typically without seeing the patient directly, relying instead on updates from the behavioral health care manager.

The team tracks each patient’s progress with standardized screening tools, such as the PHQ-9 for depression, and adjusts treatment when a patient isn’t improving – an approach known as treat-to-target.

Collaborative care connects naturally to the PCMH model described above. Where the PCMH coordinates comprehensive care across the entire health system, collaborative care is one way a practice brings mental health care into that same coordinated team.

Within this model, the medical assistant’s role includes administering patient screening questionnaires as directed by the office and recording the scores, scheduling follow-up contacts, and relaying messages between the patient and the rest of the care team.