The Blueprint

PCMH staff rising to 'top of license'

by Amanda Berra

How can PCMHs deliver higher-quality care to more patients despite real-world resource constraints, including a provider shortage? The answer is not just adding more primary care providers but also dramatically transforming the roles of clinical support staff in each practice.

In our series of blog posts examining medical home staffing trends, we explored how PCMH sites are adding staff support and health systems are developing centralized care management platforms to support practice-based PCMH efforts. This post will share updated examples and data illustrating how PCMH leaders are elevating staff to "top of license" by aligning staff responsibilities to match their credentials.

Applying the 'Top of License' Principle

Many primary care staff members are under-utilized compared to what their clinical licensure and personal potential should permit them to do.  The challenge for medical homes is to enhance staff skills and roles to do more complex, meaningful, and hands-on work. Doing this at each licensure level allows less-complex work to be offloaded from the level above--up to and including the physician, NP, or PA provider.  It should also position each provider to manage more patients in the future.


Top-of-license principles in action

Although "top of license" is an accepted catch phrase in the world of the medical home, substantive examples of what elevated roles actually look like are sometimes hard to find.

Each case study below illustrates how a particular organization has systematically boosted staff members into the types of roles most that directly advance medical homes' outcomes objectives:

Notice that although we frequently associate RNs with the medical home staff model, organizations that are innovating in this area have focused on many different clinical credentials within the primary care team.  In fact, we frequently hear of practices making receptionists and other non-clinical-credentialed staff into more active members of the medical home team.  For example, patient scheduling is actually a tremendous opportunity to touch the patient in a more comprehensive way by checking to ensure that all the needed services and supports are being provided and addressing any other practical concerns that the patient may have about the logistics of an upcoming visit.


How prevalent are top-of-license practices today?

To capture a snapshot of the top of license shift among medical home sites, the 2011 Medical Home Project benchmarking survey asked PCMH sites which staff member was the primary owner of key medical home functions, including pre-visit planning, group visit facilitation, and patient self-management support. The results from self-identified medical homes were compared to non-medical home primary care practices in our sample.

Though the difference was not statistically significant, there was more top-of-license task ownership reported among medical homes as compared to non-medical homes.

For example, when it came to pre-visit planning—i.e., reviewing patient charts in advance of an appointment to identify gaps in care, even for unrelated complaints—it turned out that medical home physicians owned the task at 12% of sites, versus 27% of non-medical home sites.


Is there a "right answer" for exactly what each team member should be doing?

As previously observed, there is a right-answer direction in staff model innovation, i.e., increasing the use of staff members with lower-level credentials (with proper support).  But there is no template for exactly what each staff member should be doing today. Staff model experiments are ongoing and different organizations are using different approaches depending on institutional and market context, such as wage cost, supply of that particular credential locally, state-level licensure standards, etc.  

Some organizations are moving through different staff approaches over time as their models evolve.

Ownership of medical home-focused tasks by clinical credential

Our data on primary ownership of different key population management tasks captured the current diversity in medical home staff roles. For example, looking at the chart below on primary ownership of patient self-management support—sometimes called health coaching—it seems that this job is currently split nearly evenly among physicians, nurses, and medical assistants. (Notice also the percentage of sites outsourcing the service (18%)—suggesting that the practice is leaning on a centralized or third-party care management platform).

Pre-visit chart review

Patient self-management support

Population data entry

Population data analysis

Source: The Medical Home/Primary Care Benchmarking Initiative, The Advisory Board Medical Home Project, 2011

Upcoming Analysis

This series of blog posts focused on PCMH staffing, including information on sites adding new staff and the use of centralized care management platforms.  In coming weeks, we will share more updates on PCMH operations, including:

  • Population management activity in PCMH practice workflow
  • PCMH access to clinical IT
  • Panel size trends and benchmarks

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