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Instead of the primary care physician gatekeeper model, provider teams are likely to assume gatekeeping responsibilities at most managed care organizations, says Francine Gaillour, MD, an internist with Seattle-based Group Health and medical director for PHAMIS Inc., an information systems firm also in Seattle. She envisions four scenarios in which care will be delivered in a provider team model:
• Population management team. The primary care physician leads the team, which consists of an RN, two or more physician extenders, and an ambulatory quality manager. This kind of team would be responsible for the majority of health plan members, who need only routine, preventive, or urgent care.
By separating high risk patients from those who require routine care, the primary care physician can focus on true population management, such as immunizations and screenings. Using information systems, the population management team can track immunization rates, for example, and follow up with patients who have failed to update their shots. The team could also query the system for the number of women at risk for breast cancer and make follow-up calls to schedule mammograms.
The team would also use physician extenders and nurses to provide routine care, such as Pap smears, and deliver patient education. The primary care physician would supervise the nurse and physician extenders, and would handle more complicated cases personally.
• The advance practice nurse and disease management team. Because the majority of a health plan’s members require only occasional preventive, routine, urgent, or emergency care, they account for only about 20% of medical expenditures. It’s commonly estimated that the chronically ill, about 20% of a health plan’s enrollees, account for 80% of resource utilization, Gaillour says.
To help manage sicker patients, this team would designate an advance practice nurse as a team coordinator. The team would consist of a specialist, a primary care physician, and a PharmD. Specialists are called upon for their ability to give precise diagnoses that will determine the disease management strategy.
• The nurse case management and demand management team. This team takes demand management a step further than the current demand management programs that require a nurse to dispense telephone advice based on treatment algorithms and assess a patient’s need for a clinic visit, a hospital visit, or self-care.
Using advanced information systems that provide on-line patient records, care can be better coordinated by the nurse case manager. This includes better scheduling and improved access to the physician who will provide the most appropriate care.
• Enhanced specialty services team. There are patients, however, who are well aware of their place in the system. They are the chronically ill whose diseases are in advanced stages. Gaillour says 90% of these patients’ care is delivered by a specialist.
In this provider team, a specialist would be the team leader, with a physician extender and a primary care physician to deliver routine care.
This team would attempt to provide all the patient’s care, rather than send the patient to another office for routine care. Using primary care and physician extender team members, the specialty services team becomes a one-stop shopping site for the chronically ill patient.
Specialty teams also would act as care coordinators for chronically ill hospitalized patients by assigning a physician to act as a primary provider for an inpatient population. To avoid discontinuity of care, the physician would be aided by computerized patient records.