Implementing team-based care effectively within telemedicine

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

AMA Chief Experience Officer Todd Unger talks to three health experts about implementing team-based care effectively within telemedicine and how it has evolved due to the COVID-19 pandemic.

Learn more at the AMA COVID-19 resource center.

Speakers

• Christine Sinsky, MD, vice president, professional satisfaction, AMA
• James Jerzak, MD, physician, Bellin Health
• Kevin Hopkins, MD, physician, Cleveland Clinic

Unger: Hello, this is the American Medical Association's COVID-19 update. Today, we're talking about implementing team-based care within telemedicine, and its important during the pandemic.

I'm joined today by Dr. Christine Sinsky AMA's vice president of professional satisfaction in Madison, Wisconsin, Dr. James Jerzak, a physician at Bellin Health in Green Bay, Wisconsin, and Dr. Kevin Hopkins, a physician at the Cleveland Clinic in Olmsted Township, Ohio. I'm Todd Unger, AMA's chief experience officer in Chicago.

Dr. Sinsky, first, why is it so important that physician practices learn how to implement telemedicine effectively right now?

Dr. Sinsky: Yeah. Thanks, Todd. Great question. So as you know, with COVID and the need for social distancing, physicians in their practices needed to find a way to care for their patients in novel ways. And telemedicine has been available for a long time, but it was really only after COVID that we saw an acceleration in the adoption of this new technology. And in fact, we have two of the pioneers in the use of telemedicine, particularly with team-based care, who are with us today.

Dr. Jerzak: Yeah. Thanks, Chris. It's great to be here. We found with the COVID pandemic, when it hit, it really put aside a lot of the regular office workflows that we were doing, and we had to adapt really quickly to the new changes, especially with the video visits and virtual visits. And it took a little bit of doing. It didn't happen easily, but eventually we got it down, and we'll talk about a little bit of that today, I think.

Dr. Hopkins: Yeah, so it was certainly inspired a direct and rapid shift in how we cared for patients. I know from Jim's organization and certainly for mine too, within a matter of about two to three weeks, we went from 98 to 99% of our visits, our encounters happening face-to-face in person in the office, to less than 30% happening face-to-face, and eventually topped out at about 90% of our primary care visits happening in a virtual platform.

Unger: How has that continued then or how has that trend maintained over the past two months or so?

Dr. Hopkins: So as we've started welcoming patients back into our offices and providing an environment that's safe for them to receive care and it's safe for our caregivers, we've swung back to the majority of our encounters taking place face-to-face in the office, about 75 to 80%, but we continue to see a persistence of about 20% of our encounters taking place virtually. Some of that is by intent and by design to maintain safe, physical distancing. And some of it is because there are certain disease processes or patient demographics that actually prefer that platform.

Dr. Jerzak: Yeah, a couple of things we noticed at Bellin, first of all, we're a relatively small system and we just couldn't sustain financially the impact of having such a dramatic decrease in visits. So we had to rapidly try to increase the video visits. And then we also realized that this COVID is not going away anytime soon. So we needed a way to coexist with COVID. And we've put a lot of things in place to try to get office visits back up in order for sustainability, but also, at the same time, trying to, in a more thoughtful manner, increase our video visit capability.

Unger: Well, Dr. Jerzak, you've implemented team-based care models in your practices long before COVID-19. Can you share your experiences and what benefits you've seen?

Dr. Jerzak: Well, one of the hallmarks of the team-based care model we developed before COVID in face-to-face visits was the uptrained staff helping us out in the room for things like documentation and order entry and things like that. So when the COVID hit and we switched to virtual visits, the workflows weren't really in place. So now we spend a lot of time quickly trying to get the workflows going to allow us to have our staff support us in the office visit during the virtual visit. And it's making a huge difference, really helping out.

Dr. Hopkins: Dr. Hopkins? I'm sorry, Chris, go ahead.

Dr. Sinsky: Well, Jim, I wondered if you could share with us what difference that's made in terms of time, your time for the visit, the staff's feeling of involvement, and the sense of completeness of the visit.

Dr. Jerzak: That's a good question, Chris. Initially, when we started doing video visits almost like overnight, we found that I was back in a room by myself trying to do all of the EHR work on my own. And I was used to having the support from the staff prior to that. So now that we've got our new workflows developed, where they're in a room and helping me with the visit with the EHR work, it's made a dramatic impact on my time. I'm much more efficient. When I'm done with my part of the visit, I'll hand the phone or the iPad back to the person helping me and she can complete the visit. And it has really allowed me to be more efficient in the office.

Unger: Dr. Hopkins, how about you?

Dr. Hopkins: So it was interesting for me to hear Jim's response to that question because I've had the opportunity to work in an advanced team-based care practice model for more than a decade now, and yet when the pandemic hit, we sort of reverted back to that doctor does all mentality, which we know to be so dangerous and detrimental to us as individuals, as caregivers, yet we go back to what we are most familiar with or most reliant upon when the crisis hit.

So our advanced team-based care model that we built over a decade ago has allowed us to realize improvements and increases in access for our patients, which then also translated to improved productivity for our health system, the ability to improve all of our quality metrics, and also improve our performance on patient satisfaction and caregiver engagement and satisfaction. It's really allowed us to really address all aspects of our care model.

Dr. Jerzak: Yeah, that's the other thing I would tag onto that, Kevin, it's not just the physician satisfaction, it's the staff satisfaction as well. And the CTCs, the MAEs and the LPNs in their role there, they're helping them in the room, they've relayed a lot of improved satisfaction and feeling that they really contributed to the care of the patient and bonding with the patient. That's been a real plus for the staff.

Unger: Dr. Sinsky, I'm curious, you and your team have spent quite a bit of time and resources improving workflows to increase physician satisfaction, sustainability. What are the biggest challenges in translating those learnings into a telemedicine environment?

Dr. Sinsky: Right. Right. Well, I think the first challenge is to just realize that it's possible. And thanks to people like Doctors Hopkins and Jerzak, we know it is possible. And we also know it's safer. And so we just have to get over the barrier that just because we're not necessarily three people in the room, the patient, the staff person and the physician, we can still give patients that more enhanced care, even if they are present in a virtual way. So I think the first obstacle to overcome is just the recognition that it's possible to do it, and then to remind ourselves that the "doctor does it all" model isn't safe. It is not efficient, but it also is less safe. When we can give our undivided attention to the patient, our care is better.

Unger: Dr. Hopkins, what guidance do you have for practices that are looking to implement this type of care model?

Dr. Hopkins: Well, I really think you just have to, for one thing, the telemedicine model, in part, is you just have to start. You have to start somewhere. So start with certain patient types, certain visit types, certain chronic or acute conditions, and evaluate and interact with those patients via the virtual platform, and continue to think about roles and responsibilities of everyone in the practice. We're all caregivers. We all have a defined skill set. We all have strengths. We all have opportunities for improvement. There's a certain amount of work that needs to get done for our patient panels and for each individual patient. And now we have a team to be able to do that.

Dr. Hopkins: So who does what I think really makes sense to have a conversation around. We need to be very clear around expectations, transparent, and then hold each other mutually accountable if and when we don't live up to those expectations.

Dr. Jerzak: At Bellin, we, from the beginning, really had the mantra that we had to have three wins. We had to have a win for the system, a win for the patient and a win for the care team. A win for the patient really was the enhanced engagement of the doctor with the patient and the enhanced engagement with the staff. The win for the system is the, even though they may require more staff, the improved quality measures and increased access, increased numbers in visits. It's a big part of it. And then the win for the care team, where people just are more satisfied with their work, which is I know a big focus of Chris's work at the AMA.

Unger: Dr. Sinsky, do you have any additional guidance or lessons learned that you'd want to share? Any specifics?

Dr. Sinsky: Yeah, happy to. I think that anyone interested in adopting a model similar to what Kevin and Jim have talked to us about can go to STEPS Forward and learn about team-based care. We have multiple modules on STEPS Forward that cover different aspects of team-based care. We have one on team documentation. Dr. Jerzak helped write one on teaming the inbox, and we have one on team based-care itself. And those really help get the underlying concept of task distribution according to ability. And once you've done that, then you can translate that to the new electronic platform.

In addition, we do have a telemedicine playbook. And once COVID lightens up for us, the AMA and Bellin every year, have a team-based care training camp that's held in Green Bay, Wisconsin in the home of the Packers at Lambeau Field, and both Doctors Jerzak and Hopkins are faculty on that team-based care training camp. We had to postpone it this year, but we look forward to it again next year.

Unger: Dr. Sinsky, what experience when you see people learn from those STEPS Forward modules and implement some of the recommendations around workflow, what kind of outcome changes do you see?

Dr. Sinsky: Right. Great question. Well, one of the things we see is that people go home earlier, an hour to two hours earlier, and they're not taking that burden of documentation work and inbox work home with them at night. We've had people, including actually Dr. Jerzak, who might've been closer to ready to retire, and now says, "I'm in it for longer because it is such a rewarding model of care."

Unger: Those are amazing results. Well, thank you so much, Dr. Sinsky, Dr. Jerzak, and Dr. Hopkins for being here today and sharing your perspectives with us. That's it for today's COVID-19 update. We'll be back next week with another segment.

For updated resources on COVID-19 go to ama-assn.org/COVID-19. Thanks for joining us today and please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.