Union Square Family Health, a safety-net clinic in Somerville, Mass., reorganized into multidisciplinary teams and restructured clinic flow to improve both efficiency and continuity of patient care. Its innovative model represents many fundamental features of integrated practice units (IPUs) but also underscores the challenges of creating primary care IPUs in a value-based health care system.
An integrated practice unit (IPU) involves a multidisciplinary team trained to provide the full cycle of care for a well-defined patient segment. IPUs in primary care may differ significantly from their specialty counterparts.
Union Square Family Health has taken steps toward a primary care IPU, caring for a well-defined segment of the Boston-area population, dividing its patient population into pods to deliver more individualized care, and restructuring clinic flow to improve efficiency. Pods were created without regard to specific medical conditions or intensity of care required, because patient needs vary over time. Registries were used to track clinical outcomes.
As at Union Square, a primary care IPU might manifest as a multidisciplinary team dedicated to a defined set of patients, with a complex care management team available as needed.
Future challenges include better integration of specialty care services and a transition to value-based reimbursement methods, such as capitation and/or bundled reimbursement.
The U.S. health care system, the most expensive worldwide, produces worse outcomes than comparable lower-cost health systems. The expansion of health insurance under the Affordable Care Act prompted debate about the best ways to efficiently deliver high-quality health care to millions of newly insured individuals.
A team at Harvard Business School, led by Professor Michael Porter, has been developing a framework for restructuring our health care system around value for patients, defined as patient health outcomes per dollar spent to achieve those outcomes. A key feature of this framework is the integrated practice unit, which includes a team of clinical and nonclinical personnel trained to provide both outpatient and inpatient care for a particular medical condition or set of related conditions. The multidisciplinary team is ideally co-located and works closely together to deliver coordinated, integrated, and high-quality care.
The integrated practice unit concept has been successfully implemented in numerous organizations providing specialty care, including at Cleveland Clinic, which in 2007 began restructuring into multidisciplinary units designed around specific conditions or organ systems. The first, the Neurological Institute, was comprised of neurology, neurosurgery, and psychiatry services. Its mandate expanded over time to encompass the full cycle of care for stroke patients; by 2014, Institute clinicians were responsible for outcomes of their stroke patients at rehabilitation facilities.
While the Neurological Institute demonstrates the potential of IPUs at a renowned tertiary care center, implementing IPUs in primary care poses a different set of challenges, because primary care addresses all patient complaints, while specialty IPUs segment patients by condition.
We set out to identify primary care practices that exemplified the principles of integrated practice units. We identified Union Square Family Health in Somerville, Mass., as a practice that segments its patient population to provide efficient, effective care to a challenging patient population and has many fundamental features of a primary care IPU.
Union Square is a member of Cambridge Health Alliance, a safety-net system serving residents of Cambridge, Mass., and nearby cities. It is located in a low-income neighborhood with a sizeable population of uninsured immigrants from Brazil and elsewhere. Soon after the clinic opened in 1998, its staff recognized that infrequent appointments with a primary care physician were not sufficient to meet the medical needs of this socioeconomically and culturally diverse community.
The Clinic’s Goal
The clinic sought to develop multidisciplinary teams to deliver comprehensive care to its patient population, divided into “pods” to allow for more individualized care.
Union Square organized patients into pods of 4,000–5,000 patients to create smaller practices within the clinic. Patients were assigned to pods with other members of their family, but without regard to their medical conditions. Each pod was staffed by two or three primary care physicians (PCPs), 1.5 physician assistants (PAs), 1.5 nurses, one receptionist, and 3–4 medical assistants. Patients had a single PCP but could see another physician or PA within the pod if their assigned physician was unavailable.
Patients were accustomed to seeing this team each time they came to clinic. Continuity was over 90% for PAs. Over time, pod teams became familiar with their patients, enabling staff to better tailor outreach efforts and clinic time to each family’s needs. All roles were well defined:
- Medical receptionist: Frontline staff represented the local community and served as cultural ambassadors for the clinic, helping bridge language barriers. Receptionists were familiar with each team’s patients and could schedule immunizations and appointments for the whole family. They helped ensure consistent follow-up, leveraging mobile technology like secure texting to contact patients.
- Medical assistant (MA): Considered the “boss” during clinic sessions, MAs managed clinic flow and guided patients through blood pressure checks, immunizations, and other activities. Before a clinic session, the MA coordinated with the physician around care needs for patients visiting that day. The MA also had a panel of patients to outreach for screening and prevention.
- Registered nurse: Nurses facilitated chronic disease management, developing relationships with patients through longitudinal educational visits. They also undertook outreach to complex patients and managed transitions of care, following patients after discharge from the hospital.
- Physician: Because other team members handled many of the screening, prevention, education, and administrative efforts that often consume physician time in primary care practices, physicians at Union Square focused on the work of diagnosing, treating, and developing relationships with patients.
- Physician assistant: Physician assistants shared a panel of patients with physicians. Patients could choose the kind of provider they wanted to see, and many received care solely from PAs. For example, Haitian patients on one physician’s team might opt to see a PA who was fluent in Haitian-Creole.
To serve the complex needs of low-income, immigrant families, the clinic also offered extended services, including a pharmacist, referral coordinator, nutritionist, psychiatrist, behaviorist, social worker, and complex care team.
Scheduling and Clinic Workflow
Traditional clinic schedules structure workflow around physician appointments, as fee-for-service reimbursement centers on the physician-patient interaction. Although reimbursement remained largely fee-for-service, Union Square reorganized workflow to reflect the multidisciplinary nature of team-based care. The new model placed patient time, not physician time, at the center of staff attention.
The restructured workflow used patient and staff time more efficiently. Visits met patients’ needs more effectively, decreasing annual visits per patient. Three years after implementing a patient-centered workflow, average yearly visits dropped from 3 to 1.5 per year, reducing wait times for clinic appointments.
The patient visit
Team members worked together to plan each encounter before patients arrived. The day before an appointment, the MA and PCP created a plan for each patient that included immunizations, lab work, or other screenings. These plans were noted in the patient’s electronic record, visible to all clinical team members planning to see the patient the following day.
When a patient arrived, planned screenings or other tasks, assigned to staff beforehand, began. The care plan was carried out before and after the PCP visit depending on clinic flow, increasing the efficiency of patient and provider time. All providers shared a communal, centralized workspace during clinic to facilitate real-time communication about a patient’s progress through his/her care plan.
At Union Square, patients were assigned to pods without regard to their medical conditions, but all patients with specific medical conditions were followed through diagnosis-based registries. This enabled the clinic to monitor patients with chronic illnesses between clinic visits, a key component of its continuous care initiative. The organization created patient registries for 20 conditions, such as diabetes, depression, and hypertension, along with complex care management. Registries included patients from across the pods, and patients with multiple conditions were in multiple registries.
Each registry had assigned staff members who met weekly to discuss everyone within that registry. For example, during the planned care meeting for hypertension, the designated staff identified all Union Square patients with a diagnosis of hypertension and reached out to those due for follow-up.
By using registries to organize chronic illness care, Union Square maintained responsibility for the ongoing care and well-being of its patients. The clinic ensured the same individual was responsible for in-reach (carrying out as much care as possible during a patient’s clinic visit) and outreach (bringing patients in for care when needed). This held team members accountable for the care of specific patients, preventing work from being postponed until it was another team member’s responsibility. Registries represented Union Square’s approach to population health management. The registries illustrate how tracking disease-specific outcomes was integrated into primary care.
The clinic closely tracked process measures to assess its model. These metrics were generally high for clinics providing care to underserved populations; for example, the adolescent immunization rate was 96%. Across all its primary care clinics, Cambridge Health Alliance tracked 20 process measures and laboratory-based endpoints for prevention, disease management, and complex care. In 2016, Union Square met or exceeded targets for 15 of the 20 measures.
Union Square has made strides toward generating a primary care integrated practice unit for a well-defined segment of the Boston-area population. The clinic focuses on an urban, non–English speaking, low-income, immigrant population.
Dividing the practice into pods, each with a dedicated multidisciplinary team, resulted in a smaller effective panel size. This allowed teams to better understand patient and family needs and care for a complex patient population. Building stronger relationships with patients was important for ensuring follow-up in a population that often traveled between Somerville and their home countries.
Union Square’s multidisciplinary teams enabled providers and staff to practice at the top of their licenses. The restructured clinic workflow allowed team members to carry out their assigned roles. Prevention was seamlessly integrated into this workflow, as medical assistants completed a screening checklist for every clinic visit and team members had time to follow up with patients as needed. Medically at-risk patients who required more comprehensive care were assigned to an extended team until they no longer needed supplemental support services.
Union Square represents many features of IPUs as defined by Michael Porter and colleagues. They proposed creating IPUs in primary care by segmenting care around subgroups of patients with similar needs (e.g., healthy, at risk, chronically ill, and complex patients). But patients’ needs vary over time, preventing the establishment of teams focused on particular risk groups while also preserving continuity of care. Union Square’s solution was to create pods to provide more individualized care to a subgroup of the population in the Greater Boston area with specific needs: urban, non–English speaking, low-income immigrants.
Accordingly, Porter’s primary care IPU might manifest as a multidisciplinary team dedicated to a defined set of patients, with a complex care management team available as needed. This was Union Square’s approach. By using pods, multidisciplinary teams, patient registries to track clinical outcomes, and a team for patients needing more intense services, the clinic provides efficient, patient-centered, value-based care.
As new models of value-based primary care evolve, practices like Union Square face challenges. First, the primary care IPUs and specialist practices in a value-based system need to be more effectively integrated. Currently, primary care providers are responsible for managing screenings such as mammograms and colonoscopies, but they do not carry out, and are not compensated for, these tests. Cambridge Health Alliance is leading the transition to involving specialists in care coordination activities occurring outside of regular primary care appointments.
Another important challenge in the transition to value-based primary care is that fee-for-service reimbursement does not compensate for between-visit activities integral to practices like Union Square. The practice receives inconsistent reimbursement for nurse visits and pharmacist teaching, and no reimbursement for time spent in care planning meetings. A recent study simulating the transition to team-based care and activities happening between visits demonstrated financial losses for practices compensated under fee-for-service. However, the transition resulted in financial gains for practices receiving capitated payments for more than 63% of payments. Moving toward value-based health care delivery will require further changes to reimbursement patterns, such as capitated payments and/or bundled reimbursement.