UCLA

Team functioning is a prerequisite to interdisciplinary healthcare teams achieving the goal of improving quality of care and patient outcomes. This three-paper dissertation examines barriers, facilitators and correlates of team functioning within patient aligned care teams (PACT), the Veterans Health Administration’s implementation of interdisciplinary primary care teams and a patient centered medical home.

Interprofessional team-based models that expand the role of support staff are increasingly adopted in primary care practices. In the first study we query team members of a newly implemented medical home to identify factors that may inhibit nursing staff self-efficacy, a belief of possessing the capacity to execute a role effectively. We analyzed data from 79 key informants’ interviews with primary care team members at six Veterans Health Administration (VA) clinics in Southern California. All sites had implemented Patient Aligned Care Teams (PACT), the VA’s version of a patient centered medical home (PCMH). We identified three themes that produce the self-efficacy necessary for successful role expansion: 1) role training 2) time and resources for roles and 3) cross-disciplinary role agreement. Clarifying the factors that impact self-efficacy for the role expansion of PACT staff can inform strategies for role transformation under other PCMH models.

The second paper aims to characterize PACT team members’ perceptions of the role their direct supervisors play in day-to-day primary care team functioning. In this qualitative analysis we review teamlet members’ perceptions of how their supervising middle managers are essential to the day-to-day functioning of PACT teamlets. Supervisors fulfill necessary leadership functions both within and across teams. They are involved in defining the specific roles and responsibilities of teamlet members, facilitating conflict resolution between teamlet members, setting expectations and mechanisms of accountability, facilitating within teamlet and cross teamlet coverage, and facilitating teamlet member initiated innovation. Within a multilevel system, frontline interdisciplinary teams continue to perceive the need for leadership by middle management supervisors from their own professional disciplines.

The primary objective of the third study is to employ a mixed-methods study design to identify modifiable practice climate factors associated with team function under PACT. We fielded a cross-sectional online survey of 818 providers and staff working in 23 VA primary care clinics in early stages of PCMH implementation. We simultaneously conducted semi-structure interviews with teamlet members. A cluster adjusted regression revealed perceived support from leadership, and satisfaction with the team were associated with team functioning. Attending local trainings, attending regional trainings, and attending trainings with team members were not. Qualitative interviews reveal substantial implementation variation in training. Identifying modifiable practice climate factors that are associated with team function at early stages of PCHM implementation can provide insight into where to invest resources during times of transition.