Talk of transforming health care abounds these days. Much of it centers on banishing fragmented, episodic care in favor of a coordinated approach that emphasizes prevention and disease management and collaboration between staff and providers to improve communication with patients.
The approach is ideally suited to the present era of rising costs, intensifying competition, and increasing scrutiny from payers. What could make more sense than helping patients manage their hypertension or diabetes so they can stay out of the hospital? Why wouldn’t a medical practice try to form close relationships with its patients and help them to manage their own health?
But changing the delivery of health care is a complex challenge, as the experience of University of Colorado Hospital’s AF Williams Family Medicine Clinic demonstrates. Eight months after launching a new model for improving the quality of its patient care, the clinic has demonstrated the strength of the concept but has not yet implemented it fully. The primary issues: staffing and the complexity of adapting a busy practice to a new way of doing business.
Mixed bag. The delivery model, dubbed APEX (Awesome Patient Experience), debuted in February at AF Williams and the Snow Mesa Clinic in Fort Collins. The goal was to streamline patient appointments and reduce wasted time and duplicated work by maximizing the skills of staff and providers, using the power of the Epic electronic health record, and gathering data to measure patient outcomes and satisfaction with their care.
In large measure, the success of APEX relies on redefining the role of medical assistants (MAs). In many practices, MAs spend a relatively brief amount of time with patients, taking their height and weight, temperature, and blood pressure, and identifying their chief complaint before leaving the room. Too often, that leaves patients alone, waiting for their providers.
The APEX model instead calls for MAs to usher patients to their rooms immediately, then gather detailed information about chief complaints, symptoms, medications, allergies, screenings, risk factors, and more. The MAs can initiate and pend orders in Epic, such as vaccinations and medications, for the provider to review and sign. When the model is fully implemented, MAs are to remain in the room after the provider enters, assisting with documenting the medical record.
The goal is to give providers more productive time with their patients, rather than repeating questions or tapping information into the medical record. And to a large extent, that has happened, said Jack Spittler, MD, a family physician who spends about three-quarters of his clinical time at AF Williams.
“Pre-APEX there was lots of duplication and data entry, which took away from interacting with my patients.” Spittler said.
Holes to plug. The biggest challenge at AF Williams isn’t the concept of APEX. Spittler and all others interviewed agreed it’s the right model for delivering high-quality patient care and vastly superior to the period before its implementation – when appointment delays were frequent occurrences and patient-provider interaction wasn’t as productive as it could be. But because of problems recruiting, training, and retaining enough MAs, today’s APEX model is a little like a V-8 engine firing on six cylinders.
“It’s going as well as it could go with the limitations we have,” said Karl Sudfeld, practice manager for AF Williams. The clinic needs 25 to 27 MAs; the number dipped to 13 to 15 early in the summer. It’s now at 22, but the less-than-full coverage in previous months affected patient flow and communication between staff and providers, Sudfeld said.
Most importantly, the staffing gaps mean the clinic has only now begun to implement APEX fully, with MAs staying for the entire duration of the patient visit.
“No one has received the full scope of the intended model,” Sudfeld said. “Staff have been discouraged that we can’t yet provide the level of care we want to. But no one wants to go back.”
Finding the right fit. Sudfeld said there is no single reason for the stubborn MA staffing gap. There were factors out of the clinic’s control, such as people relocating or deciding to change career goals. He acknowledged, however, that recruiting and retaining MAs present special challenges. New staff require extensive training in Epic and the clinic workflow, and must also be able to establish rapport with patients and providers.
“It’s the interpersonal and teamwork qualities that the model is reliant on that are imperative to what we are doing here,” Sudfeld said. “We have to think harder about that in hiring people. There is less margin for error in finding people who will function and work as part of an MA team from day one.”
Corey Lyon, DO, medical director for AF Williams, summarized the dilemma. “I’d never work at a non-APEX clinic,” he said. “But it has been a challenge to get the staff ratio high enough to be able to give the extra care that we want to provide.” Because of that, Lyon added, it’s difficult to give a final assessment of APEX.
“Right now we have fewer MAs than we need, and they are doing more work,” he said. “It proved to be more complicated than we thought to find the right personalities and to create the right mix.”
For example, staffing shortages at AF Williams disrupt communication between providers and MAs, who have to leave the exam room to work with the next patient rather than staying to complete the original visit, as the APEX model envisions.
“We’re trying to build a model of care while we’re going down the highway, delivering patient care,” Lyon said. “It’s a challenge to know if it works or not.”
Bring it on. AF Williams’ trailblazing will pay dividends across UCHealth down the road, said Robin Pettigrew, director of Primary Care and Ambulatory Services at UCH.
“Our ‘lessons learned’ provide valuable information for all practices as we continue to work on enhancing the patient experience,” she said.
Staffing isn’t the only challenge to the APEX initiative, Pettigrew said. She noted that AF Williams is a demanding multispecialty practice with high patient volumes, responsibility for training residents, and a large number of attending physicians who spend 30 percent or less of their time in the clinic. All of these factors have complicated the transition, Pettigrew said.
“I can’t emphasize enough the amount of change and challenge that has come from this initiative,” she said. “But I believe AF Williams will be successful. The team is resilient and committed to making a difference for our patients.”
From Lyon’s point of view, APEX perfectly suits the talents of AF Williams, which has been an innovation leader. It was the first of UCH’s primary care clinics, for example, to earn level 3 designation as a patient centered medical home from the National Committee for Quality Assurance (NCQA).
“We’re not afraid of hurdles and we’re not afraid of change,” Lyon said. “If we can implement APEX here, we can implement it anywhere.”