Aligning Care Teams Around Physicians Promotes Care Coordination For Patients

Experts discuss the benefits of patient-centered primary care in this Intermountain Podcast
Infectious Diseases
As of December 2017, all 83 of Intermountain Medical Group’s primary care clinics received National Committee for Quality Assurance (NCQA) recognition for Patient-Centered Medical Homes. This designation highlights the coordinated, behind-the-scenes work being done to put patients—and their preferences and needs—first.

Tim Johnson, MD, Senior Medical Director for the Medical Group, and Shauri Kagie, Clinical Manager and our Medical Group NCQA expert, spoke with Anne Pendo, MD, Internist and Intermountain’s Experience of Care Medical Director, about these patient-centered efforts.

Patient-centered Medical Home

Establishing a patient-centered medical home “is about transforming our primary care practices into what patients want, focusing on patients’ needs, and really supporting them with their preferences,” said Shauri. “We have great teams of physicians, nurse care managers, licensed clinical social workers, health advocates, care guides, mental health professionals—all of these professionals working together to help patients manage their health.”

At the Senior Clinic in Murray, for example, the care team sends out letters notifying patients of important preventive health measures and screenings. One patient received a reminder to get a mammogram, and did. The mammogram found cancer, and the early diagnosis enabled the patient to begin treatment early, too. “Those little things that our care teams are doing to coordinate care really do make a difference for patients’ lives and are saving them,” said Shauri.

Care teams coordinate and track referrals, relaying information on the patient’s care in specialty, emergency, hospital, and rehabilitation settings back to the primary care physician who then has a full, holistic picture of the patient’s care. The care teams also address patients’ barriers to accessing care such as accommodating transportation needs or making scheduling workarounds.

“One of the messages we delivered to physicians is that by putting a care team around you, we’d be able to do a much better job taking care of our patients, and I believe that’s happened,” said Tim.

“We had predicted that would make a physician’s life less busy, and actually I don’t think that’s true,” he added. “I think that in some ways it adds more work to our plates—the work coordinating with our care teams—but it adds the right work to our plates. That little bit of extra work is benefitting our patients and really for me, from a job satisfaction perspective, when I can see good patient outcomes, the little bit of extra work is completely worth it.”

Tim and Shauri also shared that Intermountain’s plans in primary care will be to expand the scope of the care team roles, including further enlisting the help of pharmacists to enhance medication adherence. Teams will strive to continually improve coordination around patients and increase use of technology to help streamline the “work to be done.”