The medical home requires building a better team

How do we get the many disparate members of our healthcare team together to provide better care in a patient-centered medical home?

Doctors (attendings and residents), nurse practitioners, nurses, medical assistants, phlebotomists, registrars, medical secretaries, social workers, community care organizers, pharmacists … the list goes on and on.

As it is right now, everyone is so busy trying to do their own job, to keep up with all of their paperwork, to click all their administrative boxes, to keep their supervisors happy, to keep the patients happy, to keep our customer satisfaction scores up, that no one really has the time or the support to even figure out how to act like a team.

Sometimes what it feels like we need to do is stop, slow down, take a deep breath, and really look at what it is we’re trying to accomplish here. Is what we are doing really in the best interest of our patients?

As Dr. Paul Batalden (one of the leading thinkers in healthcare improvement) has said, every system is perfectly designed to achieve exactly the results it gets. Clearly, what we are getting is not what we want. So we’d better design a different system.

First, we need buy in. Getting all the members of the potential team together, all at the same table, all convinced of the need to make these changes in the systems we use to take care of patients.

Perhaps the registrars at the front desk are not used to thinking about themselves as a member of a team. They see themselves as arriving in the morning for a job, punching a time clock, sitting at their computer station, answering phones, checking patients in, processing referrals.

Rewriting their job descriptions, re-tasking them so they feel ownership of the patients and the practice (and are appreciated and compensated as such) will be some of the difficult but necessary steps to take.

But we need more than lip service, more than simple platitudes or niceties to convince them that really engaging in the process of care is important, that they are an important part of the healthcare team.

Yet we do a poor job of integrating them into that team. And sometimes we don’t recognize that they (and many others) can make the lives of our patients better.

Recently a nearly blind, mildly demented, non-English speaking patient of mine was mailed a referral instructing her to set up an appointment on her own for neurocognitive evaluation. That is the way referrals are processed here. But the patient could not see or read the information on the paper, and could not have fathomed what to do with that information if she had been able to.

One of the registrars noticed on her return visit that she had not made the appointment, and gently, almost lovingly, guided her through the process right there at her desk. Maybe not the most efficient way, maybe not the way the system was set up for referrals, but it got the job done. And everyone felt better.

That registrar was a member of the team.

We need to help all the members of the team see these patients as their responsibility, their mission, and that their day-to-day job involves more than just the busy work and the administrative work. That it involves the actual caring, the taking care of the patients, helping them to achieve better health.

We are going to be breaking apart the traditional mold, recreating the roles of all those involved, to build a better team.

Fred N. Pelzman is associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

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  • FFP

    The medical home is an idiocy, like the entire concept of a healthcare “team”, once it involves more than 3-5 individuals. The same way one cannot govern by committee, one cannot heal by committee either. Involving too many people in somebody’s care, without anyone being the clear leader (where the buck stops, in every sense), is just recipe for disaster.

    Have these people looked around? When nurses don’t have a professional mentality (“I am on a break”, “My shift is over”, “It’s not my patient” etc.), what can one expect from less educated, less motivated, allied healthcare workers?

    You know that something is just politically-correct foul-smelling gaseous substance when it sounds just too populist and bombastic. PATIENT-centered medical HOME, ta-DA! How does that sound??? Like “NO CHILD LEFT BEHIND”. Anybody who grew up in socialism or has read “1984″ would smell it from a distance.

    You want to incentivize people to do a better job? There are some very easy ways, well-known for centuries. None of them involves telling them how to do their jobs, burdening them with more bureaucracy and more administrative parasites that live on their backs.

    • NPPCP

      Another good one – “It takes a village”.

      • Mike S.

        “It takes a village”.

        …to produce an idiot? /s

    • buzzkillerjsmith

      The wonderful thing about being in Dr. Ps position is that he and others like him can hand wave the details of actually implementing these things away. Moreover, if these are tried and then fail miserably, it is quite possible for a pundit to advocate some new foolishness in the expectation that everyone will have forgotten the old foolishness. Finance of course gives the prime examples of this.
      Dr. P’s post has no merit. It completely ignores those normal human incentives that you and azmd have so eloquently described.


    Good Afternoon Dr. Pelzman,
    I can tell you when APRNs are able to practice in a team where they can take full responsibility for their actions and practice without unnecessary supervision, they will be 100% on board; no questions asked. Every team member should practice under their own license and become accountable for everything they do; when licensure is an issue. This simple action will move healthcare in a positive direction overnight.
    Posted Respectfully.

    • FFP

      100% agree. You just have a different mentality when the buck doesn’t stop with you, regardless how much you think you care for the patient. I understood this when I graduated my residency.

      Becoming an attending is somehow like becoming a parent. Suddenly it’s not taking care of somebody else’s children; they are YOUR children. They are YOUR patients. You want to protect them even more than before; it’s much more personal.

    • Guest

      Give me a break. You’re on board until you screw up and the lawyers come looking for blood. No doubt you’ll point them in the direction of the MD. You’re ready to be independent until things get hard.

      • NPPCP

        Hi Noni, please Re-read the post. I agree with you. When the NP is “supervised”, some of the blame may fall on the physician. When the NP practices fully under their own license, the entire blame rests with them. NPs in independent practice states are completely liable for their actions. I think you and I would agree that is the way it should be. Though coming from different viewpoints, we end at the same place. We all need to be responsible for our own actions as licensed providers. Thanks for encouraging me to rephrase. Hope all is well!

  • Margalit Gur-Arie

    ‘Recently a nearly blind, mildly demented, non-English speaking patient
    of mine was mailed a referral instructing her to set up an appointment
    on her own for neurocognitive evaluation. That is the way referrals are
    processed here.”

    And this is the problem in a nutshell. This is your patient. I presume that you made the decision to refer. How come you did not take care of things for her? Why did she leave your office without an appointment for the evaluation in her hand?
    Or maybe the referral was made by a “team member” and you had no idea that it was made (which is wrong too), and the “team member” was as blind as the patient.

    Maybe there shouldn’t be one size fits all for how referrals are “processed”.

    There is no excuse for what happened to this patient and having the receptionist take pity on her after the negligent act occurred is not the right answer. I don’t know of any small private practice where something like this would have happened.

    • guest

      Most likely a small DIRECT PAY private practice.

    • southerndoc1


      Someone said that the goal of the PCMH movement was to make large practice as effective as small ones.

      I replied that, no, the goal is to make small practices as inefficient and ineffective as large one

      • azmd

        His office may not be disorganized and poorly run. It could very well be efficiently run to do exactly what it is meant to do: provide healthcare “services” that on paper meet all regulatory and QA metrics while at the same time not leaving “excess fat” in the staffing. This, of course, results in non-personalized care, but since there’s no metric that tracks that, it’s of less concern.

    • PrimaryCareDoc

      Agreed. When I make a referral, the patient leaves the office with an appointment with that specialist. There is no excuse for this.

  • guest

    There is a saying we have all heard of: “You can’t get blood from a stone.” I believe this sentiment is relevant to medicine today, as providers at all levels are asked to do more work than they are humanly able to do even in an expanded workday.

    Clearly you are too busy, either to personally oversee an individualized referral for this patient, or to get involved in the referral process at an administrative level so that it becomes more effective for all patients.

    And yet, it is somehow verboten for doctors to point out that they and healthcare providers at all levels are not being given the time they need to do their jobs well. Instead, we see time being spent on the promulgation of platitudes about “ownership” and “lean management” with the implication that if only we could all have better attitudes, or work more efficiently, that we would succeed in delivering adequate healthcare even when the time constraints are insurmountable. You just can’t get blood from a stone, and until we begin to recognize that, and feel brave enough to speak out about it, we will continue to deliver sub-par care to an increasingly disillusioned patient population.

    • buzzkillerjsmith

      I think docs speak out but still nothing changes. It has to do with incentives. The overlords benefit when we stay late and work for free. They’re not feeling our pain.

  • azmd

    This piece started off on a promising note, with acknowledgement of the fact that healthcare workers at all levels are increasingly pressed for time and experiencing workplace stress that prevents them from functioning effectively as a team and delivering personalized care. So far, so good.

    I am a little surprised, however, by the proposed solution, which if I read it correctly, could be summarized in this manner: “We have been moderately successful in forcing doctors to expand their workday without a corresponding increase in compensation. Let’s see if we can “re-task” all other medical workers so that they can reliably be expected to use their own, unpaid time to provide the personalized care that our current system is not willing to pay for. We can call it ‘ownership’ and present it as ‘the right thing to do for our patients’ and maybe the registrars won’t expect to be paid for providing it, either, just like the docs.’”

    • buzzkillerjsmith

      Boxer in Animal Farm: “I will work harder.”
      Old Major and the other pigs are quite happy with this.

      • Alice Robertson

        HA! And eventually the team walks on their back legs and snort in the same manner of those they replaced:)

  • May Wright

    “Recently a nearly blind, mildly demented, non-English speaking patient of mine was mailed a referral instructing her to set up an appointment on her own for neurocognitive evaluation. That is the way referrals are processed here.”

    This is why I don’t understand why you all insist on calling it a “patient-centered medical home”.

    Nothing about this transaction was “patient-centered”. You sound like a technocrat, and your poor patient like just a generic unit of human flesh to be “processed”.

    As Margalit Gur-Arie points out, This is your patient. YOUR patient. Think about that for a while. Really.

    “We are going to be breaking apart the traditional mold”, you crow. Well yes, yes you apparently are. It’s just a pity that we seem so blithely accepting of the fact that our patients are ending up as collateral damage in this grand demolition job.

    • Guest

      I found it depressing that he boasts proudly that HIS patient who fell through the cracks was handled by someone in his office staff who likely has a high school degree. Ridiculous.

  • buzzkillerjsmith

    Perhaps a career in ENT would be preferable.

  • kjindal

    Where I work (large nursing home / rehab center) the medical “team” concept inevitably results in NO OWNERSHIP of the patient. Everyone except the PMD can divorce themselves from any real responsibility. The physical therapists, speech therapists, dietitians, social workers, etc., all become “consultants” who spend minimal time & effort dealing with the patient, but produce a (billable) document for the chart with a meaningless “recommendation” that the PMD must address. Sometimes these recommendations are even conflicting e.g. speech therapist says puree diet but dietitian recommends mechanical soft.
    Furthermore, because they can all wear the “consultant” hat, the PMD becomes a scribe, entering dietary &other others into an arcane computer system that wouldn’t have been considered modern even 15 yrs ago.
    “patient-centered” and “team” are not just neutral harmless terms in healthcare today, rather they are actually destructive to care & ownership. Ultimately patients are definitely getting worse care despite more resources being thrown at them.

  • Guest

    This post is so very sad to me. Just as pigs at the slaughterhouse are no longer sentient animals but rather “pork producing units,” patients are no longer people but rather boxes to be checked off by each member of the “team.”

    The caring has gone from healthcare.

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