Welcome to the first ever BHP blog post (name pending licensing/creative ideas). In this blog, I hope to explore issues ranging from best practices in primary care to health policy and beyond. Today’s post is based on a site visit to one of Cleveland’s own high-performing primary care practices. If you want me to visit and write about your practice, just ask!
Neighborhood Family Practice’s (NFP) Ridge Road site doesn’t look like much from the outside. It sits next to a modern supermarket in an aged strip mall. The view left, right, and up is train tracks, freeways, and Cleveland’s gray winter sky. But the inside is different; the inside is beautiful. The NFP team has designed a practice that makes team-based care possible.
Last month, I visited the Ridge Road NFP site. NFP is a Federally Qualified Health Center with four locations on Cleveland’s West Side. From its website: in 2014, their 19 providers (three midwives, seven physicians, and nine nurse practitioners) cared for over 16,000 patients. Of their patients, 82% make less than 200% of the Federal Poverty Level (less than $47,700 for a family of 4) and 10% have no insurance, in a state that expanded Medicaid. NFP is excelling in a variety of ways, but in this post I want to focus on one feature: team co-location.
The entrance of the building leads to a waiting room lined by windows on the left and a front-desk reception area on the right. The far wall is covered with sky-blue poster boards on which dozens of community members have written why they love health insurance: “I now have peace of mind.” “Because I have the right to have medical services.” “Es importante para tu salud.”
Beyond the reception area, the clinical area begins with a set of offices dedicated to mental health services. These offices – plus the occupied exam rooms – were the only closed doors I saw in the entire practice.
The practice is divided into five different teams: three teams that deliver primary care, one team that is a refugee clinic, and a fifth team that is lead by midwives for pre- and post-natal care. Each team works from a dedicated team room. Team rooms contain four or five open cubicles that line the walls in such a way that the view of each desk is unobstructed from any given seat. Instead of private offices, two providers (usually a physician and nurse practitioner), one nurse, and one care navigator sit and work together in the team rooms. Each primary care team cares for approximately 2,000 to 3,000 patients.
When I have written and spoken about team co-location in the past, I often hear the same two concerns. One, how does anybody get any work done, and, two, who — other than the wealthiest practices — can afford to remodel their practice to create team rooms?
In response to the first concern, yes, at times providers need a private space to call their patient with sad news. But most of the time, working side-by-side with colleagues invites face-to-face verbal communication, which is far more efficient than the asynchronous communication of electronic medical record messages or e-mails. Those who already work in a small open space can tell you that if a telephone call requires silence, they need only ask. Large open spaces with a dozen or more workstations create a bigger challenge to find that same silent opportunity.
The second concern – who can afford to redesign the interior of their practice to support teams – has always been the more difficult challenge. Many of the practices that I have visited either were lucky enough to inherit the right floor plan, which subsequently allowed them to become a high-performing primary care practice, or they rebuilt from the ground up, a costly endeavor.
Neighborhood Family Practice proves that team co-location can be achieved a third way, not through luck or through riches, but through vision. NFP has the vision to recognize that by knocking down walls in their storefront location on Ridge Road, they can build better teams.
What’s the payoff? Don Berwick and colleagues proposed the Triple Aim: better experience of care, better health outcomes, and lower costs of care. Tom Bodenheimer and Chris Sinsky proposed a fourth aim: less staff burnout. I think in the short run, this fourth aim is where team co-location is most impactful, creating more joy in practice.
Primary care can be lonely, difficult work. Co-location can change it to work that is shared and celebrated as a team. It may be too early to tell if NFP is closer to reaching the Triple Aim, but their personnel do appear to love what they do and believe they have the tools to do their job well. That is an aim to which all primary care practices can aspire.