Team-based and collaborative care is one of the seven shared principles of primary care.1 Shared responsibility for patient care has the opportunity to allow all team members to work at the top of their training, improving patient access, care coordination, and decreasing provider burnout. Even prior to the COVID-19 pandemic and associated rise in telehealth, many groups have explored the opportunities of a virtual-first hybrid clinic.2
The Tera Practice model adopts team-based care principles augmented by tech-enabled care and communication in a primarily virtual care environment. The Tera Practice model was established in 2018 as a virtual-first practice servicing Palo Alto, California. The “pod” team model includes a physician, nurse practitioner (NP), licensed vocational nurse, and health coach. We use a virtual-first hybrid model where 90% of interactions occur via secure messaging, telephone, or video visit, which provides accessibility benefits for the patients who can get most of their care from home or work. Our care team members work from home, and the virtual-first model frees up physical clinic space (and associated costs) and provides flexibility to accommodate the care team’s personal needs (such as childcare or home-based responsibilities). This has significantly increased work satisfaction amongst team members. However, there is one dedicated in-clinic day for the team to address patients’ needs that must be in person to maintain continuity and connection with our patient panel.
This team-based, patient-centered model has already shown impact for improving patient access, care quality, and cost.3 The model is replicable and scalable with three “pods” operating across Northern California. Reflecting on our experience, we opine that there are three main enablers of virtual team based primary care: 1) encourage asynchronous patient communication, 2) establish “virtual back office” communication channels, and 3) apply daily synchronous team huddles to communicate essential team care items.
Embrace the In Basket
Healthcare leaders and frontline physicians have concerns about the ever-expanding in basket increasing clinician burnout.4 However, asynchronous modalities, such as secure chat through the patient portal and store-and-forward images of rashes, allow for triaging, multitasking, and task distribution. The in basket is shared across the pod (physician, NP, nurse) and each team member is empowered to respond to patient concerns to their level of clinical knowledge and current workload creating a more efficient use of everyone’s time. For example, in a traditional office setting, three separate patients may need a 1) work note for recent illness, 2) rash evaluation, and 3) blood pressure check and medication refill, requiring three clinic slots and an hour of everyone’s time. Leveraging a distributed work model, those three patients are helped in a fraction of the time. For example, for those same three concerns, 1) the physician takes 10 minutes on a video visit to discuss with the patient about the work note, while in parallel; 2) the NP reviews the rash image and messages the patient with an over-the-counter medication recommendation;, 3) the nurse reviews the blood pressure logs that the patient messaged in and pends the medication refill for the physician to sign as soon as they complete the work note visit. While the work is distributed, continuity of care is also preserved because we collaborate as a tight-knit team, and huddle daily: we divide, conquer, and, most importantly, reconvene.
Utilize Omni-channel Communication Strategies in the Virtual Back Office
In a traditional physical clinic office, simple requests like “Please schedule Ms. Jones for a follow up next week,” or “How do you order a Podiatry referral?” were all conveyed verbally in the workroom. In a completely virtual office environment, virtual care team communication takes more than just e-mail. The channels of communication (especially HIPAA secure communication) are significantly more complex. Our team utilizes multiple channels based on urgency of request and level of care team sharing required. For example, if a patient needs an urgent medication refill, our nurse may directly message the physician on Microsoft Teams. If a team member discovers a helpful clinical workflow, they post it to our virtual whiteboard in a shared OneNote document. We avoid e-mail because our work e-mail inboxes are already too cluttered. If a patient needs a COVID-19 test, our nurse will message our Teams group chat so the physician or the NP can sign the order (the nurse will pend it). If a patient has multiple team contacts for an ongoing issue like a new cancer diagnosis, then we will document our touchpoints on a shared “High Risk” patient list within the electronic health record (EHR). Since most messaging occurs via written communication only, it is important to remain cognizant of tone and the way messages are perceived. Setting clear expectations for response times, responsibilities, and acknowledging message receipt are essential to virtual back-office communication.
Collaborate via the Virtual Huddle
Clinic huddles have often been a method to efficiently share information, collaborate, and coordinate.5 The Virtual Clinic is no exception, and so we huddle daily each morning to allow all team members to sync on schedules and address any clinical care escalations. It is also the central hub of our data-driven care coordination at Tera that gives us the opportunity to review key clinical quality metrics and patient panel health indicators regularly.
In the virtual care environment, time makes up for touch. While the team (and often the patient) are not physically co-located, as a team we can have multiple checkpoints with the patient over a longer period of time. Rather than episodic 15-minute visits monthly, our team provides proactive monitoring and early intervention for any alarm symptoms. Flexible communication modalities, a collaborative platform, and team-based care enables higher quality, timelier care and a better experience for patients and the entire care team.
- Epperly T, Bechtel C, Sweeney R, et al. The shared principles of primary care: A multistakeholder initiative to find a common voice. Fam Med. 2019;51(2):179-184. doi:10.22454/FamMed.2019.925587.
- Cheung L, Leung TI, Ding VY, et al. Healthcare service utilization under a New Virtual Primary Care Delivery Model. Telemed E-Health. 2019;25(7):551-559. doi:10.1089/tmj.2018.0145.
- Taylor Y, Scrase R, Fung L. Caring for patients virtually: Lessons from a successful Virtual Primary Care Practice webinar. https://www.pbgh.org/event/caring-for-patients-virtually-lessons-from-a-successful-virtual-primary-care-practice/. Presented at California Quality Collaborative April 30, 2021. Accessed January 15, 2022.
- Adler-Milstein J, Zhao W, Willard-Grace R, et al. Electronic health records and burnout: Time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. J Am Med Inform Assoc. 2020 Apr 1;27(4):531-538. doi: 10.1093/jamia/ocz220.
- Stewart EE, Johnson BC. Huddles: Improve office efficiency in mere minutes. Fam Pract Manag. 2007;14(6):27.
Clinical Practice, Health Policy & Advocacy, Leadership, Administration, & Career Planning, Medical Education, SGIM, Wellness
Dr. Sakumoto (email@example.com) is a virtualist primary care physician and informatics physician champion at Sutter Health. Ms. Brosnan (brosnaMI@sutterhealth.org) is a licensed vocational nurse at Sutter Health. Ms. Guiterrez (firstname.lastname@example.org) is a family practice nurse practitioner at Sutter Health. (All authors are part of the San Francisco “pod” of Tera Practice.)
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