Adding more value to the visit

​Primary care clinic redesigns doctor appointments to maximize time of patients, providers
Jan. 23, 2017

We’ve all experienced it: waiting for our doctor in the lonely exam room only to get a few minutes to voice our most pressing health concerns. It’s an old model of care and one that doesn’t lend itself to the growing demands on doctors or the increase in chronic issues among their patients.

A docor examines a patient
Dr. Robert Juhala, left, with UCHealth Internal Medicine in Fort Collins, examines James Waibel while Medical Assistant Noelle Encina documents Juhala’s notes. Having an MA document allows providers more valued time with their patients. Photo by Kati Blocker, UCHealth.

“The model of care for patients is well over 100 years old and suited to when major problems were acute illnesses, such as infections, or acute injuries,” said Dr. Austin Bailey, a 30-year physician and now primary care medical director for UCHealth’s provider group, UCHealth Medical Group. “The concept of chronic disease wasn’t prevalent at the turn of the century, but as we progressed through the Industrial Age, we’ve taken on this huge burden of chronic disease, and it requires a different model of care.”

UCHealth has found a new model and will begin implementing it in several clinics starting Oct. 31. Every six months, the model will be launched in additional clinics, Bailey said.

The Primary Care Practice Redesign model came from University of Utah Health Care and was adapted to fit the needs of UCHealth and its patients. A successful pilot recently wrapped up at UCHealth Internal Medicine (Snow Mesa) in Fort Collins and UCHealth Family Medicine (AF Williams) in Denver.

“You feel like you are being treated the second they [the medical assistants] take you back to the room,” said Rich Cortez, who’s been seeing Dr. Cathy Ow, an internal medicine physician in Fort Collins, for 20 years.

The redesign leans heavily on medical assistants, an entry-level health care position.

“MAs really become navigators for the patients in this new model,” said Dawn Maupin, operations director for primary care at CHMG.

Each provider gets 2.5 MA support people. The half-time MA manages the physician’s phone line and messages, while the other two work with the physician and the patients the minute they arrive.

“We greet the patient by name and walk them back to the room,” said MA Noelle Encina, who started working at UCHealth Internal Medicine in Fort Collins just prior to the redesign. “Before, we’d call the patient’s name from the door, work them up routinely and ask them what they wanted to been seen for. Vitals were the only thing we’d enter in the chart. Basically, we were just rooming and taking vitals.”

In the new model, Encina stays with the patient during his or her entire visit. While waiting for the provider, she not only charts vitals but also records the main reasons for the patient’s visit as well as information on family history, health maintenance and routine preventive care. She then guides the patient in prioritizing what he or she wants to discuss with the doctor and afterward schedules additional appointments.

“It is team-based care opposed to an isolated physician working alone,” Bailey said.

The MA is scheduled for 20 minutes with the patient. Then there is a warm handoff, where the MA quickly updates the physician on the information obtained. The provider then has 20 minutes with the patient.

Although the amount of time scheduled hasn’t changed much, time is not wasted waiting, Bailey said.

“The provider has 20 minutes with you not at the computer, typing or reading, but talking with you and coming up with a plan,” he said.

This is possible because the MA is documenting while the provider is talking. The MA then stays in the room after the provider leaves to go through the plan and make sure it’s understood by the patient, schedules additional visits, such as preventive care exams, and handles any other details, such as giving a flu shot. Then the MA escorts the patient out.

“I noticed right away that Cathy [Ow] was able to spend a lot more time with me,” Cortez said of his visit under the new model. “She’s always done a really good job, but having a medical assistant there helps the process. It frees her up so she can talk face-to-face and get to the root of a problem.”

Provider and staff perspective

The model has not only increased patient satisfaction, it has improved efficiency, quality of care, job satisfaction, and team dynamics and communication at its pilot clinics, according to an outside evaluation.

“With the old model, every visit was cutting corners because you had to assume you were never going to be able to do everything. Having been a primary care provider for 30 years, I know that eats at you when you walk out knowing things are undone,” Bailey said. “With this model, you see they are getting done. There is that fulfillment that you are doing a good job. It’s not only easier but literally more fulfilling in every sense of the word.”

Providers reported more comprehensive and productive visits with more satisfied patients, according to the evaluation. And it showed improvements through better documentation, better follow-through on care plans and better delivery of consistent and reliable preventive and chronic disease care. Providers reported fewer after-hours charting and reduced burnout once the model was running smoothly, and MAs reported an increased level of empowerment and job satisfaction.

It took a bit to get there, Bailey said, acknowledging that everyone needs time to get a feel for the new design.

“The MA has to get used to my voice, what I do and how I do it,” he said of the MA’s role in documentation support during the provider’s visit with the patient. “That team concept has to be developed. So, when you first roll out the model, everything slows down.”

Likewise, providers had to get used to someone else writing their notes.

“One challenge was that trust level, especially with exam notes,” Encina said. “Doctors have always done them, so to allow us to go in there and document that note — what it was they were saying and their findings — took a lot of communication and going through after to make sure we did understand them correctly. But now, doctors compliment us on getting details of a visit that they may have not included in the note because of time. Once we started, they saw that the experience of us completing it was working, and now a lot of them will say they can’t function without us.

“My favorite thing is that I get to see and follow that patient through their whole visit,” she continued. “I don’t get a complaint and wonder what happened. I actually see the reason why we ordered a CT or MRI. I’m seeing the actual outcomes. The patients are more willing to open up to me because we’ve established that relationship. This is important because we are at the front of the patient’s health care team.”

There were still other challenges that Encina and her colleagues faced while implementing the model, Maupin said.

The clinics nearly doubled the number of MAs on staff but didn’t increase work space. As a result, MAs had to learn how to provide a balance between shared and personal space. There also was a period of worker fatigue as the changes were underway, she said.

“It was difficult,” Encina admitted. “There were team members who felt it was too much of an increase in expectations and work flow. But once we got into the swing of things, we started implementing our own education.”

And that has continued. Each Friday morning, the care team meets, learning about new information and evolving protocols and addressing questions.

“It’s great that it’s going to be implemented across UCHealth,” Encina said. “I encourage people to embrace this change, to be fully on board and to understand that more education and opportunity comes with it. I encourage them to be excited and take the initiative.

“It doesn’t happen overnight, but the gratitude you get from this new model is amazing.”

About the author

Kati Blocker has always been driven to learn and explore the world around her. And every day, as a writer for UCHealth, Kati meets inspiring people, learns about life-saving technology, and gets to know the amazing people who are saving lives each day. Even better, she gets to share their stories with the world.

As a journalism major at the University of Wyoming, Kati wrote for her college newspaper. She also studied abroad in Swansea, Wales, while simultaneously writing for a Colorado metaphysical newspaper.

After college, Kati was a reporter for the Montrose Daily Press and the Telluride Watch, covering education and health care in rural Colorado, as well as city news and business.

When she's not writing, Kati is creating her own stories with her husband Joel and their two young children.