By Dr Hector Rodriguez
All too often, attempts to implement new team-based models of care are met with resistance – “our practice is different, so this won’t work here,” or “our patients are more complicated than other practices, so this won’t work here.” Given the increasing and expanding demands on frontline primary care clinicians and staff, there is an urgent need to effectively adapt implementation strategies to ensure that all practices benefit, especially for practices that are perceived as “too different” to implement a new team-based approach to care.
Previous studies of implementation effectiveness consistently conclude that it is critically important to allow clinicians and staff the flexibility to implement new models so that organizational changes meld with “real world” demands of local dynamic health delivery settings. Flexibility is thought to enable stakeholders to engage in the implementation process. Too much flexibility in team-based care approaches – or, a low-fidelity of implementation – however, can result in reduced “potency” of delivery system interventions.
In our study examining the integration of patient health coaches and registered nurse care managers within an integrated physician network, we discovered wide implementation variability across five practice sites adopting the team-based primary care approach. Among certain practices, we found new team members were not incorporated in a patient-centered manner. In these practices the new team members’ skills and knowledge were underutilized in spite of similar implementation resources and guidance for frontline clinicians and staff. In interviewing clinicians and staff, it became clear that stakeholders wanted even more opportunities for inter-organizational learning, including forums to share best practices, implementation lessons, and approaches to improve patient engagement in care. Flexibility, however, resulted in each practice prioritizing different clinical performance measures as central to their improvement plans; inconsistent performance goals across practices limited inter-organizational learning opportunities.
In summary, our results underscore the critical importance of fostering a productive learning environment when stimulating change across a health delivery network; one in which physician leaders align and engage care teams on the central vision, goals, and outcomes of care team practice. While practice stakeholders may perceive their settings as being too unique to implement team-based approaches, our study highlights implementation challenges when too much latitude is given in defining implementation processes and goals.
To aid the transformation of primary care, we call for more evidence on effective implementation approaches which encourage flexibility and adaptation to unique demands of diverse practice settings, while adhering to potent components of delivery system interventions.
You can find the related Healthcare article, “Flexible implementation and integration of new team members to support patient-centered care”, here.