Aims The aim of this study was to evaluate the impact of the Teamlet Model on care of patients with diabetes and/or hypertension in a primary care residency practice. We compared measurement of body mass index (BMI), assessment of smoking status, development of a self-management plan, testing for HbA1C and LDL, and reaching goals for blood pressure, HbA1C, and LDL in the intervention group prior to and during implementation of the Teamlet Model. We also compared changes in testing for HbA1C and LDL and reaching goals for blood pressure, HbA1C, and LDL in the intervention group to changes seen in a comparison group of similar patients at the same clinic. The study was approved by the institutional review board of the University of California, San Francisco (UCSF).
Setting The San Francisco General Hospital Family Health Center (FHC), a family medicine teaching clinic, is the largest primary care clinic within the San Francisco Community Health Network, serving more than 10,000 active patients. The patient population is racially and ethnically diverse (39% Latino, 27% Asian, 17% White, 13% African American), with 83% uninsured or covered by Medicaid. Patients speak 29 different languages: most common are English (42%), Spanish (25%), and Cantonese/Mandarin (8%). The FHC is the primary ambulatory training site for the 41 resident trainees in the UCSF Family and Community Medicine Residency Program.
Participants One hundred forty-six active patients who (1) transferred from graduating third year residents to incoming first year residents, (2) had at least one visit in the previous 2 years, (3) spoke English, Spanish, Cantonese, or Mandarin, and 4) were diagnosed with diabetes and/or hypertension. This cohort was identified after elimination through attrition (27 patients moved, transferred care, died, or became inactive) or refusal (7 patients). Patients with severe mental illness or dementia were excluded.
Comparison Group Patients A comparison group of 395 patients was constructed of all FHC patients who (1) had second and third year resident providers, (2) had at least one visit in the last 2 years, (3) spoke English, Spanish, Cantonese, or Mandarin, and (4) were diagnosed with diabetes and/or hypertension.
In 2006, the Teamlet Model was piloted on a small scale at the FHC8
. Building upon the pilot, during the 2007–8 academic year, we expanded the Teamlet Model to 13 first-year residents, 11 health coaches, and approximately 150 patients. This implementation coincided with our participation in the California Academic Chronic Care Collaborative, a practice improvement collaborative involving teaching clinics throughout California.
In early 2007, all FHC nursing staff, including medical assistants and health workers, participated in health coach training. In contrast to medical assistants, health workers in our system have training in patient education, but no clinical training. The training encompassed collaborative partnership with patients9
, action plans for healthy behavior change10
, medication adherence, and an overview of cardiovascular risk factors including diabetes. Training required active participation through role-plays to develop skills in behavior-change action plan negotiation, medication reconciliation, and patient-centered communication11
. The health coach training curriculum is available at www.ucsf.edu/cepc
. After six initial training sessions, the FHC medical director and nurse manager assigned all available medical assistants and health workers (11 in total) to be health coaches. Ongoing training involved live observations, mentoring, and case discussions to further build patient communication skills. Total training time ranged from 14–16 h, and competency was determined through direct observation by the trainers.
An interactive seminar series was designed for 13 PGY1 residents, covering the Chronic Care Model with specific sessions on clinical guidelines and evidence, self-management support, the use of registry data, community resources, and patient perspectives on living with chronic illness. Seminars included protected time for teamlets to review their patient panels, using registry reports as tools for panel management12
. Training continued during clinical practice as faculty observed the resident-coach teamlets and provided feedback on both team and patient communication.
All PGY1s had continuity clinic at the same time, allowing them to work with a consistent group of faculty who only supervised PGY1s during that time. During the Teamlet Model intervention, chronic care clinics were held within the regular PGY1 clinic afternoons once or twice a month. For these intervention clinics, the 13 PGY1 residents and 11 health coaches were paired in language-concordant teams. These teamlets were stable: residents and patients always worked with the same health coach. Four to six patients with chronic cardiovascular risk factors were scheduled during each clinic session. Teamlets and supervising faculty huddled during the first 30 min of clinic, discussing scheduled patients and prioritizing higher risk patients for coaching.
The health coaches expanded the physician visit with a pre-visit for agenda-setting and medication reconciliation, and a post-visit to engage patients in behavior-change action plans and to check patient understanding and agreement with the clinician’s care plan. In addition, health coaches called patients between visits to follow-up on action plans and medication adherence and to help patients problem-solve and navigate the health care system. Teamlets chose to apply all or parts of this delivery model to individual patients based on time and prioritization of patients who were more complicated or needed more assistance. Health coaches generally saw two to four patients during each clinic.
Measures Data prior to and during the intervention were used to assess changes in process and outcome measures, and to compare changes to a similar group of patients who did not receive the intervention. Three clinical processes were assessed for teamlet patients only (measurement of BMI, assessment of smoking status, and formulation of a self-management plan) by chart review prior to the intervention and at the time of each visit during the intervention year. Two clinical processes (measurement of HbA1C and LDL) and three clinical outcomes (HgbA1C, LDL, and blood pressure) were assessed for both Teamlet Model and comparison group patients for the year prior to implementation of the Teamlet Model (February 2006 to January 2007) and during the implementation year (July 2007 to June 2008) from electronic medical records (HbA1C and LDL) and by hand review of patient charts by research assistants (blood pressure). Variability of blood pressure measurements was not controlled as values were gathered from clinical chart review. If more than one value was available for any given measure in a 1-year window, then the most recent value was used.
Data Analysis Key patient characteristics were compared for patients in the intervention and comparison groups using chi-square and t-tests. Process outcomes were all dichotomous variables (measurement of BMI, assessment of smoking status, formulation of a self-management plan, and measurement of LDL or HbA1C in the past 12 months). Clinical outcomes (HbA1C, LDL, and blood pressure) were coded dichotomously based on commonly used ‘at goal’ values as follows: HbA1c <7.0, BP (<130/80 for diabetes patients; <140/90 for hypertension patients), and LDL (<100 for diabetes patients; <130 for hypertension patients). To examine change in the proportion of patients meeting health outcome goals prior to the intervention compared to the intervention year, McNemar tests were conducted within the intervention and comparison groups. Changes in process and outcomes from the year prior to the year during implementation of the Teamlet Model were assessed using logistic regression analyses adjusted for baseline values of outcomes and, in a separate model, for baseline values and patient characteristics (age, gender, language, and diagnosis). All analyses were performed using SPSS version 17.0.