Radical Reinvestment in Interprofessional Team-based Primary Care - by Erin Sullivan
As we exit the pandemic, it is increasingly clear that primary care needs a radical reinvestment in interprofessional team-based care to increase the sustainability of its workforce. The pre-COVID decade encouraged transformation to team-based primary care, which was intended to ameliorate burnout, increase physician satisfaction, and improve patient outcomes. Unfortunately, teamwork within primary care was negatively impacted by the pandemic and we need to re-visit and re-invest in rebuilding the teams we had before.
The last keynote I gave before COVID-19 arrived was titled “Primary Care: A Team Sport,” and the manuscript was shelved because of the pandemic. I studied 15 exemplary primary care organizations through site visits; we analyzed over 147 interview transcripts, and evaluated observational data from meetings and shadowing care teams. I expanded on an initial set of team principles based on what was happening in practice. These were the key additions, which are worthy of consideration as we exit the pandemic and attempt to rebuild primary care, and interprofessional team-based care:
Team size varies by context and population. Ideally, each clinician is part of a multidisciplinary team that is tailored to the practice’s context and available resources. The teams we observed varied in size, from 2 to 8 members, and included a range of the following roles: medical assistants, nurses, nurse practitioners or physician assistants, community health workers, pharmacists, care and population managers, and health coaches.
Team members that can manage behavioral health issues and the social determinants of health improve coordination and continuity of care. Practices with expanded integrated teams, meaning pharmacists, behavioral health clinicians, social workers, or community health workers who were available within the primary care clinic for consults or warm hand-offs improved coordination and continuity of care. Availability of these expanded team members at the same appointment, or via a warm hand-off, often eliminated the need for patients to make additional appointments, and ensured that multiple facets of a patient’s needs were addressed.
A high degree of trust and stability contributes to high performing teams. Teams that build longitudinal relationships, in part through working together all the time, create a high degree of trust in each other. The best team is a stable team. Teams that work together over time had a culture of collaboration and solidarity that was especially valued when the work was challenging and complex.
Top of license work = happier team members. Team members working at the top of their professional license felt challenged by, and engaged in, their work and were more likely to stay with the organization, thus leading to stable care teams.
Include the patient on the care team. Practices that considered the patient a member of, or at the center of, the care team, found that patients will learn to rely on all members of the care team, not just the physician. By creating space for patients to be part of the team and build relationships with all team members, trust was built, and patients knew that their needs could be met through interacting with any member of the team.
It is important to remember that teams operate within the broader context of the organization, and remarkably, all of our study sites had an organizational culture characterized by 1) trusting, long-term relationships with patients and colleagues; and 2) purposeful approaches to redistributing power, authority, responsibility, and action away from physicians to other care team members, patients, and families. These dual aspects (relationships building and power shifts) are especially important because toxic cultures were a driver of the Great Resignation across all industries.
The pandemic highlighted that work environment matters, and that the primary care work environment is reaching a breaking point. In a May 2023 article, “Primary Care in Peril: How the Clinicians View the Problems and Solutions,” my co-authors and I analyzed over two years (March 2020-March 2022) of survey data collected by the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good to illustrate the crisis in primary care. We used the data from the survey series to highlight what our primary care clinician respondents told us, which is that they encountered layers of stress and struggle everywhere: with patients; within their practice; in the health system, community, and society-at-large.
There is urgent work needed to improve payment and policy to keep primary care viable in the U.S. health system, but the worrisome issue of maintaining, and increasing, a sustainable primary care workforce to care for all patients remains. A primary care physician shortage was looming pre-COVID and could worsen given the number of physicians leaving practice, reducing hours, or switching specialties as the pandemic wanes. Further, our survey data showed only 22% of practices were fully staffed, and that work conditions deteriorated during the pandemic, with primary care clinicians reporting overwhelming workloads, burnout, and mental health issues.
Adverse work conditions make it difficult to recruit individuals to careers in primary care, or to encourage retention in primary care jobs, regardless of whether they are physicians, advanced practice clinicians (APCs), medical assistants, social workers, care navigators, or administrative team members. The 2021 National Academies of Science, Engineering, and Medicine (NASEM) recommendation to renew the focus on inter-professional teams because the work of primary care has grown such that all team members are important in caring for each patient is mission critical. If we cannot create a workplace where primary care team members want to work, feel fulfilled, and are able to go home most nights not feeling stressed, overwhelmed, or beyond their maximum capacity, we will not have a viable primary care system in the U.S. because no one will want to do this job.
The ability to make the workday end at the end of the workday may be the single most important challenge facing primary care. This will take substantive investment of resources; radical team restructuring feels like the way forward to make the primary care workforce sustainable. Fixing primary care, and (re)building the robust teams that it requires will not happen overnight; it is hard to trade short-term financial gains for the longer-term return on investment in the current environment, but patients and clinicians need the support that teams can provide. As one survey respondent described, without the necessary supports in place, arriving to clinic each day was “…like showing up to a fire with a squirt gun.”
Dr. Erin Sullivan is the inaugural David Meyers Award winner for her paper, Primary Care in Peril: How Clinicians View the Problems and Solutions