Scholars of the Patient Centered Medical Home (PCMH) have generated a robust literature to illustrate that the interprofessional (IP) model of primary care delivers value. When IP care and IP culture are maximized, a practice can achieve that tantalizing goal of improving patient care while simultaneously reducing provider and staff burnout.1, 2 IP education is a crucial adjunct to this schema, as training all members of a practice in one another’s capabilities maximizes true team functionality.3
The experience of our resident clinic, native to Northwell Health’s Long Island Jewish (LIJ) Hospital and in recent years transitioned to a community location, illustrates some of the promise and pitfalls that one might encounter in trying to transform one’s clinic into a high-functioning IP environment. I have been core faculty in our institution’s grant-supported, intensively interprofessional IMPACcT clinic4 for six years and have, along with outstanding colleagues, had the privilege of teaching IP education principles regionally and nationally. In assuming directorship of the LIJ clinic as we prepared for our move, I was enthusiastic about relaunching the practice in highly interprofessional form. I am hopeful that the following discussion of our journey will help to offer some ideas as well as some cautions to those on a similar path.
Demonstrate Commitment to IP Leadership and Processes
Coming into my tenure as clinic director, I was fortunate to inherit a culture oriented towards positive IP interactions. Our full-time faculty featured within its ranks our clinical pharmacist, double appointed at St. John’s University and Northwell, and acknowledged as a crucial part of practice leadership. Huddles had been put into place to lead off patient care sessions ever since the practice became a PCMH, and IP staff attendance was expected at each.
Make Sure Your IP Staff Feel They Are Valued Stakeholders in the Practice
Weekly Practice Improvement Team (PIT) meetings were also instituted upon PCMH certification, conducted every Monday as a working lunch. Faculty leadership, residents, Registered Nurses, Medical Office Assistants, Care Managers, Registered Dietician, Social Workers, Medical Secretaries, and Front Desk staff regularly participated in these meetings, working together to optimize practice workflows and policies. This gave every member of the team a consistent opportunity to contribute to practice design, enhancing mutual commitment and sense of practice ownership.
Educate Administration that IP Resources Are Not an Extravagance, but Fundamental
The most clinically significant unmet need in our PCMH was ready access to Behavioral Health (BH) resources. Advocating for an embedded BH practitioner provided a lesson both in the value of direct action and in the limitation of this approach. After a lengthy series of diplomatic emails, phone contacts and intra-divisional strategizing yielded no tangible resource, I opted for a blunter approach. Righteously citing our patients’ high level of need, the repetitive ED visits that could be avoided with BH access, and the inequity of resources across resident practices at our institution, I was able to secure an in-person meeting with the BH service line leadership and essentially insist upon a commitment towards an embedded practitioner.
…But Be Prepared with a Clear Plan for Resource Implementation
Direct advocacy with those best positioned to provide material help seemed to unlock some resources. We moved to the head of the line to onboard a BH practitioner via a recently launched, government-sponsored program. What I had not sufficiently accounted for was that the constrained physical space our clinic occupied at that time would soon undermine the delicate arrangements we had made. Despite faculty willingly ceding already scant room to our new BH professional, the crowded space and limited available technology gave his supervisors the likely quite accurate impression that we could not meet the program’s minimal support requirements. Our long-sought BH practitioner was pulled from the practice and it seemed that many months of effort had gone for naught.
Maintain Resilience through Setbacks
The experience taught several lessons. I’d thought the missing link in our BH effort was a strong pitch to administration, and advocacy with the right people in power had seemed to make a difference. But without an adeptly designed infrastructure for our new BH practitioner to feel valued and productive in our practice, the IP collaboration for which I’d fervently hoped could not materialize. In the long view, however, the collapse of this shared effort did make our institution’s BH leadership very aware of our practice’s specific needs. When our clinic’s physical circumstances changed, we were first in line for another chance to bring a therapist into our practice.
Active Listening for Opportunities Pays Dividends
We caught a break a few months later when our long-planned move to a more spacious location finally came together. We now would have the workspace we’d need to expand access for patient visits and better deploy IP staff. At this point, certain opportunities seemed to present themselves for the taking—so long as we seized upon them when we first heard any inkling of a development that might help us. Keeping an ear to the ground for institutional and local initiatives that could potentially yield clinic resources became the centerpiece of our IP team construction strategy moving forward.
Collaborate Creatively to Develop Programs with Willing IP Colleagues
When the BH service line suggested they might be able to free up a Care Manager to provide counseling a few days a week, we pounced on the opportunity. We were able to take advantage of a nascent collaboration with the psychiatry residency to embed senior residents as consultants within our practice. We worked to develop this relationship, and it has become the linchpin in caring for our patients with severe mental illness. Collaborating with our always-innovative Psychiatry colleagues to weave together our new practitioners’ services, we soon developed a truly integrative BH team.
Recognize When Promising Opportunities Fall into Your Hands
A collaboration between LIJ’s in-house pharmacy and our institution’s new commercial pharmacy venture created the opportunity for us to embed a pharmacy liaison in our practice, to help with securing access to medications for our patients with the least financial resources. This practitioner has expertly reduced the substantial burden that medication prior authorizations impose upon clinicians, thereby permitting us to more boldly prescribe therapies that we otherwise might have counted out as unattainable for our coverage-challenged patients. Pharmacy faculty meanwhile managed to open a channel for pharmacy residents and students to join our team huddles. Productive collaborations with substance misuse counselors, attorneys, and social workers from a medical-legal partnership with Hofstra University Law School, community health workers operating within a Medicaid-driven initiative, and a state grant-supported Cancer Screening Program have followed.
IP Education Burnishes IP Care
The more IP educational moments we create, the more integrated our IP care has become. We continue to run our PIT meetings every Monday and afford time in each huddle for IP practitioners to contribute within their areas of expertise. In our annually organized QI projects, we place IP collaboration front and center, ensuring that project design is optimized by content experts throughout and maximizing what we can achieve for our patients. At the outset of this academic year, all staff worked together to design a case-based resident orientation session which prominently featured our diverse IP offerings, aiming to drive optimal collaboration from day one.
IP Care Is the Future for Primary Care Physicians
If we want to do well by our patients while preserving our own wellness and hold out any hope of representing primary care as an appealing career to our current residents, we must maximize the IP presence in our practices. To achieve these goals, a number of approaches can work. But if we really want to build resident clinics’ IP offerings in the current business environment, one within which clinician-educators have to Robin Hood many of the resources we need, it will be crucial for our SGIM community to work together to deftly identify and nimbly deploy all the effective strategies that we possibly can.