UCLA

Background: In 2011, a large integrated healthcare organization implemented a primary care team redesign in five pilot practices to improve the delivery of patient-centered chronic illness care and augment the physician-medical assistant dyads by adding two new primary care team roles for each practice - a nurse care manager (NCM) and a patient health coach (PHC). This work examines three aspects of implementing the care team redesign:

1) The facilitators and barriers of implementation,

2) The impact of the team redesign on practice climate,

3) The relationship between fidelity of implementation (FOI) and intervention effectiveness in terms of improved patient outcomes.

Methods: Three separate approaches were used to examine the aspects of implementing care teams including conducting 22 key-informant interviews of care teams members at the five pilot practice implementing the practice team redesign, conducting a longitudinal practice climate survey among 542 clinicians and staff, and using a convergent mixed-methods approach to determine the degree of FOI and its associated impact the on changes in outcomes of diabetes care for each site.

Results: Facilitators and barriers of implementing the care team redesign differed due to flexible protocols in program implementation, intended to allow each practice to best fit the redesign to suit local needs. Successful practices (n=2) reported increased team communication and functioning as a result of high physician engagement and local leadership facilitation. Overall practice climate of pilot practices improved, though improvements were not significantly different than non-pilot practices. Finally, FOI was a consistent predictor of improvements in diabetes care outcomes across the sites, particularly for practices with the highest and lowest FOI ranks. Despite a general association between FOI ranking and patient outcomes, underlying patient characteristics, including patient age and co-morbidities, influenced both FOI and change in diabetes outcomes over time, suggesting that patient complexity may mitigate the care team redesign's effect on improving patient outcomes.

Conclusion: When implementing primary care teams across practice networks, standardized scope of practice of personnel, common quality improvement priorities, and shared performance metrics may be helpful in improving implementation experiences, practice climate, patient outcomes and disseminating effective redesign strategies.