As part of the initiative, each clinic's team includes at least one physician, nurse, nurse practitioner, social worker, care manager and medical assistant.
Every morning the team huddles for about 15 minutes to go over the day's agenda. Quality metrics are discussed as well, including measures that need to be improved upon.
The medical assistant works closely with the physician throughout the day to address patients' preventive needs. Prior to seeing the doctor, the patient will see the medical assistant to discuss any vaccinations or screenings like mammograms or colonoscopies they might need.
All 40 OSF clinics in the initiative have reached the goal of vaccinating 78% of eligible patients for pneumococcal pneumonia. Team-based care has other benefits as well. A study published in JAMA last year showed the model vastly improved screening for depression and adherence to diabetes protocols.
Physicians, such as Dr. Michael Maloney at OSF Medical Group–Guilford Square, say it helps them focus on the patient's main problems and concerns.
Near the end of the patient visit, Maloney goes through all the preventive tests and consults with the patient on why the suggested tests are needed.
Nurses are also used extensively under the model so the clinic can see more patients. If a patient calls for an appointment to treat common ailments like a urinary-tract infection or strep throat, an appointment is made with a nurse instead of a physician.
Nurses are also used if the physician or advanced practitioner ordered a follow-up appointment in a few weeks for a complex patient but it only requires a quick check-in to discuss how they are managing their disease.
"We are able to offload some of these appointments that are appropriate for the nurse clinic—it has improved our access," Maloney said. He sees about 18 to 21 patients per day at the clinic.
Pumilia, the nurse at OSF Medical Group–Guilford Square, has taken on side projects as well. For example, she is currently going through the electronic health records to identify Medicare patients who haven't yet had their annual wellness visit. She calls patients to remind them of the benefit of annual exams and encourages them to set up an appointment.
The visit "is so comprehensive—I spend an hour with them going over every aspect of their life and educating them about ways to keep them from getting sick," Pumilia said.
Since OSF Medical Group–Guilford Square kicked off the Care Transformation initiative in January, Pumilia said she's felt like she can really practice to her full capacity. "It really makes a difference to feel like there is a team behind me."
Maloney said the daily huddles took some getting used to. The staff now has to come in 15 minutes earlier. "But once we started huddling, very quickly we saw the value in it," he said.
OSF Medical Group plans to expand the Care Transformation initiative to its remaining 29 clinics by April 2018.
