US Primary Care Teams and Coordination

Problem

Aging of the population and increasing prevalence of chronic illness have increased the demand for US primary care (PC) services. One approach for addressing this increased demand is PC teams that include physician associates (PAs) and nurse practitioners (NPs). While a variety of team models exist, an essential characteristic is that members share a team definition and that team members be interdependent (require interaction to complete work). To be effective, team interdependencies must be recognized and coordinated. Our objective was to understand if/how PC professionals define team, team membership, and describe how they coordinate work.

Approach

This mixed-methods study utilized surveys and semi-structured interviews of PC professionals (doctors=12, NPs=8, PAs=4, medical assistants (MAs) and nurses=4 (N=28)) from 8 Duke Primary Care clinics. Surveys obtained demographic information and descriptors of team design. Sixty-minute individual, audio-recorded interviews explored team definition, membership, interdependence, and coordination mechanisms (relational, electronic, physical/visual, meetings, routines, and boundary spanners). Survey data was analyzed using descriptive statistics. Interview data was analyzed using a content analysis technique utilizing descriptive and pattern coding. Coding was initiated using a priori codes from the literature. All data were transformed into binary variables and displayed in an array table to support the recognition of patterns and paradoxes.

Findings

Ninety-percent of participants reported being on a team with other PC professionals (providers (doctors, PAs and NPs) and/or other professionals) with 16% considering themselves to be on multiple clinic teams. Descriptions of team membership fell into several categories: 1) PC provider (PCP) + MA; 2) PCP + MA + other professionals; 3) PCP + MA + other providers; 4) other professional teams such as MAs only or nurses only. However, important within-clinic variations in definitions of “team” were widespread. Only 20% of providers reported being on a team with other providers, but all describe significant interdependence in the form of sharing patients. All participants reported utilizing multiple mechanisms of coordination. However, relational coordination appeared to be predominant between staff as well as providers and staff. Electronic coordination appeared to be predominant between providers.Wide variation in team membership within PC exists. Despite significant interdependence, providers often do not consider other providers to be part of their team. This finding, paired with the small number who do not consider themselves to be on teams, suggests variation in the definition of team. Approaches to coordination within PC may vary between different professionals.

Consequences

A goal of US primary care redesign is to improve efficiency and quality of care delivery through team-based practice. These goals may be thwarted if team definition and membership is unclear or multiple team membership and variation in coordination practices exist. These findings can inform team-based interventions to improve quality and efficiency of primary care delivery, particularly for those considering incorporating PAs on their team.