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Table 2 Primary Care Staff Organization, Roles and Activities in LEAP Practices

From: Effective team-based primary care: observations from innovative practices

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.
Clinic-Community Connections • 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.