|Innovation Area||Major Trends||Promising Innovations|
|Primary care team structure||
• Providers and their panels are supported by a core team built around strong provider-MA partnerships.|
• Multi-provider core teams often include, RNs, and front desk staff.
• Core team members including PCPs share offices and work spaces.
• Extended practice teams often include RN care managers, behavioral health specialists, and pharmacists.
|• Each PCP works with 2 MAs, who remain with each patient throughout their visit—doing intake, scribing for the PCP, and handling post-visit questions and issues.|
|Enhanced role of medical assistants||
• MAs review charts of scheduled patients and lead core team huddles to plan care.|
• MAs arrange or deliver most preventive care procedures.
• MAs often involved in outreach to patients with care gaps or needing follow-up.
• MAs are actively involved in Quality Improvement and play leadership roles.
|• MAs with additional training in self-management support and diabetes care conduct individual and small group visits with diabetic patients.|
|Roles of Registered Nurses||
• Core team RNs provide follow-up care, skills training, and self-management support to chronically ill patients in nurse encounters or conjoint visits.|
• Team RNs use nurse visits and standing orders to manage common acute illnesses.
• RN care managers work with small panels of high risk patients.
|• RNs use delegated order sets to titrate medications for patients with common chronic conditions—e.g., warfarin, anti-hypertensive drugs.|
|Layperson Patient Care Roles||• Laypersons help patients address needs for information, community resources, and coordination of their care.||
• Laypersons trained in self-management counseling serve as health coaches.|
• Layperson EMR experts make changes to the EMR supportive of quality improvement.
|Managing Complex Illness||
• RN Care Managers work with small panels of sicker patients, including those discharged from hospital.|
• Behavioral Health Specialists, other social workers, and lay care coordinators/community health workers address psychosocial needs.
• Pharmacists provide Medication Therapy Management services to multi-problem patients.
|• Weekly or bi-weekly case conferences convene multi-disciplinary clinic staff to discuss challenging patients and develop a comprehensive care plan, and review progress of previously discussed patients.|
|Behavioral Health Integration||
• Core team (MAs and RNs) involved in depression screening and follow-up.|
• On-site Behavioral Health Specialists facilitate warm handoffs and provide short-term therapy and crisis management.
• Advice on psychotropic drugs is obtained from on-site or consulting Psychiatrists or Psychiatric NPs.
|• Patients on chronic opioid therapy are tracked, asked to sign contracts, and offered in-clinic buprenorphine therapy if warranted.|
• Practices hire staff from populations served by the clinic.|
• Designated practice team members help patients identify and access community services.
• Practice actively cultivates partnerships with community organizations to address social and environmental issues.
|• The practice works with other agencies in the community to address social determinants of health.|