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Journal of General Internal Medicine

, Volume 33, Issue 11, pp 1928–1936 | Cite as

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system

  • Anita D. Misra-Hebert
  • Adam Perzynski
  • Michael B. Rothberg
  • Jaqueline Fox
  • Mary Beth Mercer
  • Xiaobo Liu
  • Bo Hu
  • David C. Aron
  • Kurt C. Stange
Original Research

Abstract

Background

Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care.

Objective

To identify practice setting components contributing to uptake of new team-based care models.

Design

Convergent mixed-methods design.

Participants

Employees and patients of primary care practices implementing two team-based models in a large, integrated health system.

Main measures

Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team.

Key results

Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups—high, partial, and low uptake of new team-based models. Uptake was related to (1) practices’ responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices’ ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices.

Conclusion

Uptake of new team-based care delivery models is related to practices’ ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.

Key Words

Primary care redesign Health care delivery Qualitative research 

Notes

Acknowledgements

These results were presented in part at the Society of General Internal Medicine national meeting in Washington, DC in April, 2017 and in Denver, CO in May, 2018.

Funding Information

Dr. Misra-Hebert is supported by an Agency for Healthcare Research and Quality grant K08HS024128. Dr. Stange’s time was supported by a Clinical Research Professorship from the American Cancer Society.

Compliance with Ethical Standards

Conflicts of Interest

Dr. Misra-Hebert has received research funding from the Merck Investigators Studies Program and from Novo Nordisk, both unrelated to this work. Drs. Perzynski, Rothberg, Hu, Aron, and Stange, and Ms. Fox., Mercer, and Liu report no conflicts of interest.

Supplementary material

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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Anita D. Misra-Hebert
    • 1
    • 2
    • 3
  • Adam Perzynski
    • 4
  • Michael B. Rothberg
    • 1
    • 2
  • Jaqueline Fox
    • 2
  • Mary Beth Mercer
    • 5
  • Xiaobo Liu
    • 3
  • Bo Hu
    • 3
  • David C. Aron
    • 6
  • Kurt C. Stange
    • 7
  1. 1.Department of Internal Medicine Cleveland ClinicClevelandUSA
  2. 2.Center for Value-Based Care ResearchCleveland ClinicClevelandUSA
  3. 3.Department of Quantitative Health SciencesCleveland ClinicClevelandUSA
  4. 4.Center for Health Care Research and PolicyCase Western Reserve University at MetroHealthClevelandUSA
  5. 5.Office of Patient ExperienceCleveland ClinicClevelandUSA
  6. 6.Louis Stokes Cleveland Veterans Affairs Medical CenterClevelandUSA
  7. 7.Center for Community Health Integration, and Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, Oncology and SociologyCase Western Reserve UniversityClevelandUSA

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