Sorry I forgot to do a basic budget breakdown that illustrates my focus on incorporating good team science in primary care.

Say we have a team of :
MD, APN, RN & (licensed)
CMA/Certified health worker (unlicensed but certified)

APN salary ave $45/hr
RN salary ave $ 27/hr
(10 yrs plus but likes ambulatory care &
we have data that is often the case since hosp
care is challenging/high burn out area)

CMA/ CHW salary ave $14/hr

So essentially as MDs need to monitor team efficiencies you need to determine what staffing level meets:
Patient satisfaction
Non pharm & Pharm guidance.

Nonpharm can come from all personnel
Pharm guidance from RNs with protocols
(ie. Certified Db educators/ Certified Asthma managers)

APNs/ PAs can see & prescribe but who are you comfortable with them seeing & when. In other words should late evening visits by APNs/ PAs be only semiurgent but less chronically ill. That is until the MDs train the staff
1/3 of offices utilize these personnel. Perhaps we need a meta analysis of the best training practices.

Clinical utility & Patient satisfaction may be enhanced with good capital management. That includes intellectual capital.
If CHWs can do nonpharm at 1/3 the price of APNs, why not give them the lifestyle classes. (Which we know have challenging adherence rates anyway).

A statistician & good HR consultant can stratify the costly end for your business. In addition, a good certified RN can see the emotional cases up front & reduce the MD conversation time. (This is no different than an executive VP delegating to account reps). It is a better attempt at maintaining clinical utility.

Perhaps we need to expand the space to allow patients to vent longer with less expensive personnel. Adding space is usually cheaper than adding personnel.

In addition, cross training personnel is usually cheaper as well. (RNs with phlebotomy or with case management certs are one example. PAs/ NPs with suturing or stress test experience are another).

Retraining is also cheaper than firing. Some examples of groups that will train NPs/ PAs further include:
Fitzgerald Health Education Association
Practicing Clinicians Exchange.

Please understand that this message does not mean that your current practice is following good management guidelines. In fact, I also want to express best wishes for all that you already do. It is just that HC is so expensive now, every dollar counts. The most prudent managers make the most of the team.

Kit.

Many of you make valid points. Simply put we have undercapitalized primary care.

What does this group think about using greater amounts of the following
a) Certified case management RNs &
b) Certified APNs/PAs for semiurgent care +
c) Certified Community Health Workers

In addition, do people agree that we need to keep hospitalists in many centers to provide communication to primary care ?

In other words, shouldn’t a primary care med home include:
MDs (*Who can focus on strategic plans/ & sickest)
APNs with First Assist & ED training
PAs &
Decent certified RNs (not just CMAs)

If we have some consensus on this team science, then we need to ask:
How many of each discipline?

This number may be based on the acute vs chronic mix. In fact demography, geography & SES also influences outcomes as well. So historically our poorer patients might need more hands on.

Now you will ask, how likely is that? You would be right to be skeptical as any public health receives only 5% of the budgets. That is a serious mistake for the aggregate system. This is also why I encourage all DOMs to have someone participate at APHA.

I also think that the Dr. Kevin Pho is pointing out;however, that capital truly counts. We need more of several types of personnel.

That is we need more strategic primary care directors ,MDs, & more trained operations’ personnel including:
(APNs, PAs & ambulatory certified RNs).

Finally we may need better usage of community health workers (CHWs). There is an APHA team currently integrating certification requirements for CHWs.

With the advance of smart phones, CHWs could help a lot. This may be particularly important since the data is showing our cultural guidance classes aren’t influencing the HC disparities. (Nonverbals & culture congruity count not simply professional backgrounds).

As times change, I hope that we agree that this is a complicated HC paradigm. Our best efforts are only that. With so many aged & chronic care patients, we have to alert society where our limits are. They deserve our candor

My best regards to you all,

Kit

Replace:
City Police….. with Security guards with masters degrees in Criminal law!
Firemen….with a neighborhood watch who can use a rubber hose!
Senators…. with an internet ballot system…let’s face it we, THE AMERICAN PEOPLE, can all read and write…Why shell out $400K/yr X 2 for 2 idiots who have no idea what they are doing and want to raise taxes just to prove it.

If we can dumb down medicine for anyone to do it, we can do anything! Why not just make the “Save money” IDEA a blanket policy for all Americans.
…Do you think the unions are listening???

In fact, many of us on these blogs have made it clear that we DO NOT support more government intervention/interference in a system that one could argue the government broke.

If Obama gets his way and “rhams” this “reform-that-isn’t-really” bill through, I suspect a number of states are going to start filing lawsuits – arguing some of the very points you’ve brought up.