Teamwork required in the medical home.

The patient-centered medical home movement is getting increasing attention and support from governmental and private insurers, as evidenced by multiple ongoing demonstration projects across the United States. Four primary care physician organizations have endorsed and defined the critical elements of the medical home concept, including the American College of Physicians (www.pcpcc.net/content/joint-principles-patient-centered-medical-home). But how does one go about building a medical home? What elements need to be in place before a patient-centered medical home (PCMH) can be established? The most important of these is teamwork.

As our practice in San Antonio began the journey to convert from a traditional to a medical home model, we found that the adoption of team-based care was both a challenge and an opportunity. I was taught self-reliance from my early years as a resident and medical student. On more than one occasion, I was coached: "If you don't do it, it won't get done." Not surprisingly, then, adopting a team approach in service of the medical home model required significant personal transformation. We needed to change our self-concept and our approach to practice.

We began by creating time and space for reflection. We instituted a weekly 1-hour meeting that included all our staff and clinicians. Initially, we used the time to agree on our mission and vision of the practice. In subsequent meetings, we started tackling problems that prevented our vision from being realized.

For example, we recognized the problems caused by the excessive demands on our front office staff to both answer phone calls and attend to patient arrivals, and together set out to solve them. The solution emerged not from the clinic manager or the physicians but from those on the front lines. Eventually, we adopted a system where almost all the people on our staff are medical assistants and the phones are answered in a separate location from the front desk. The use of medical assistants in this role allowed us to address patient issues more quickly and appropriately in-stead of piling up messages for the doctors to return at the end of the day.

We also use our weekly meetings to celebrate compliments from our patients, to track the changes we are implementing, and to identify areas that need attention and follow-up. We had skeptics at first, but now there is protest if the meeting is canceled.

In the process of developing our team, we came to appreciate the importance of the seven characteristics of effective relationships: trust, respect, diversity, mindfulness, interrelatedness, varied interaction, and effective communication (Fam. Pract. Manag. 2006;13:47-50). We also have been able to break down the wall that often separates physicians from staff (Fam. Pract. Manag. 2008;15:20-4). We have both staff and physicians involved in second-order problem solving, looking not for temporary solutions but for solutions that change the system permanently. For example, we reduced the excessive phone calls from pharmacies for refills by implementing a fax-based system.

Staff members at our research center are evaluating one of the medical home demonstration projects, TransforMED, and have studied more than 500 primary care practices over the last 2 decades. And indeed, as in my practice's experience, early findings show that the PCMH is not just a list of structures and processes, but is about developing a team approach. And not only that: Our center's experience shows that while a team approach to patient care is a cornerstone of the PCMH, a team approach is also needed to initially implement the PCMH. This is hard work and requires exquisite attention to building team relationships. So now, when I coach our residents and medical students, my motto is: "If you join the team and the team is engaged, it will get done."

DR. JAEN is the codirector of the Center for Research in Family Medicine and Primary Care at the University of Texas Health Sciences Center in San Antonio.

BY DR. CARLOS ROBERTO JAEN