In the last decade, health centers have been recalibrating their approach to primary care.  In response to increased patient loads and in order to establish Patient Centered Medical Home (PCMH) and other quality improvement initiatives, many health centers are moving strongly toward a team-based approach, which is well-documented to serve patients effectively and efficiently.  But how a health center builds the team and how the team is prepared to work together vary across the country.  Which practices are the most effective, the most essential for a team-based approach to work?  According to the executive staff of Community Health Center, Inc. (CHC), the largest Federally Qualified Health Center (FQHC) in Connecticut, one key is the role of the Medical Assistant (MA).

Three years ago, a project called LEAP, Learning from Effective Ambulatory Practices, sought to guide health centers toward high-quality team-based care by gleaning best practices from across the country that are applicable in different scopes of service and diverse environments, from rural to urban health centers, from large clinics to small ones.  With support from the Robert Wood Johnson Foundation, they honed in on 31 exemplary practices that they studied on-site and in-depth with a small team composed of a clinician, a researcher, and a patient engagement representative. 

“When we found well-developed teams, we could identify that there was a core ‘teamlet,’” explained Margaret Flinter, APRN, PhD, Senior Vice President and Clinical Director at CHC and National Co-Director of LEAP.  The ‘teamlet’ consistently featured a primary care practitioner (PCP) and an MA.  “That primary care practitioner might be a Nurse Practitioner, a physician, or a physician’s assistant (PA), but there was always a primary care practitioner and always -- 100 percent of the time -- a medical assistant,” she emphasized.  Often, the core teamlet also featured a registered nurse (RN) or a licensed practical nurse, and occasionally the core team also featured a behaviorist.  If those clinicians were not in the core teamlet, Dr. Flinter noted, “they’d be in the immediate team surrounding the teamlet, and then there was another group often around them of people like pharmacists and additional behavioral health or specialized case managers,” concentric rings of care expanding out from the core teamlet.  But at the heart, always the PCP and MA.

In Connecticut, CHC has expanded the role of the MA to be more than a support staff member; the MA is integral in supporting a patient panel and the multiple practitioners associated with that panel. CHC assures the MA is well-integrated into the teamlet beginning with their workspace, which they call the “interprofessional pod,” in which their teamlets are co-located. “It has a lot of people working together -- the provider, the behaviorist, the MA, the RN -- all co-located in one place, sitting together, allowing them to easily collaborate on the patient in the same space,” explained Veena Channamsetty, MD, the Chief Medical Officer at CHC.  One pod at CHC contains two PCPs, 2 MAs, one RN, and a behaviorist. Dr. Flinter noted that this set-up works well in small settings -- one pod per clinic, for example -- and large settings, where seven or eight pods may be housed under one building. 

Another key to their approach is a reliance on data.  Team members are given “actionable data,” explained Mary Blankson, APRN, Chief Nursing Officer at CHC.  The team meets at the start of the day to review the extracted data on their “planned care dashboard” for each patient.  “It gives [the MA] a task list, [she or he] can work on behalf of the patient to accomplish as many things as possible… before the PCP even enters the room,” which empowers MAs to proactively and independently identify and address needs a patient may have. MAs have standing orders to perform a number of key tasks, including uncomplicated UTI screening, pupil dilation, pregnancy testing, STD screening, emergency contraception education, as well as performing comprehensive diabetes visits and comprehensive asthma visits.  MAs can also access CHC’s population dashboards, to view her or his patient panel as a whole or a subset of the patient panel.  An MA can “look at the diabetic panel and say, where am I in my retinal screening?  How can I go from 50 percent to 60 percent?” noted Blankson.  (Dr. Channamsetty emphasized that an MA is not supporting a PCP but supporting a panel, typically an 18-month active patient panel ranging in size from 1100 to 1500 patients.)  CHC relies on the daily data to give all members of the team a full understanding of the day’s work ahead.  All the data is uploaded nightly from the electronic health records so that the morning’s dashboards are up-to-date. 

In Connecticut, MAs are not permitted to provide medication to a patient, limiting the scope of their work compared to MAs in other states.  Nonetheless, CHC asks a lot of its MAs; it provides a lot as well, in terms of ongoing training and support and team incentives.  In addition to completing more traditional tasks such as document handling and processing, MAs are retinal camera operators, quality improvement leaders and microsystem participants, and screeners for drug and alcohol abuse.  MAs are eligible for the same tuition reimbursement programs provided to all other staff members.  Team-based incentives provide financial compensation to all members of the team, not just the PCP, for productivity and quality improvements.