The empowerment paradox as a central challenge to patient centered medical home implementation in the veteran's health administration

Abstract

In this paper we present results of a mixed methods study conducted to identify barriers to team function among staff implementing patient aligned care teams - the Department of Veterans Affairs' patient centered medical home (PCMH) model. Using a convergent mixed methods design, we administered a standardized survey measure (Team and Individual Role Perception Survey) to assess work role challenge and engagement; and conducted discussion groups to gather context pertaining to role change. We found that the role of primary care providers is highly challenging and did not become less difficult over the initial year of implementation. Unexpectedly over the course of the first year nurse care managers reported a decrease in their perceptions of empowerment and clerical associates reported less skill variety. Qualitative data suggest that more skilled team members fail to delegate and share tasks within their teams. We characterize this interprofessional knowledge factor as an empowerment paradox where team members find it difficult to share tasks in ways that are counter to traditionally structured hierarchical roles. Health care systems seeking to implement PCMH should dedicate resources to facilitating within-team role knowledge and negotiation.

Teamwork and Delegation in Medical Homes: Primary Care Staff Perspectives in the Veterans Health Administration

“…The VISN 23 Lab has focused on the experiences of 22 primary care teams distributed across the VA Midwest Healthcare Network located in the central U.S. Both Labs are conducting a mixed-methods practical formative evaluation 28 to understand factors affecting variation in implementation, as well as experiences and perspectives of frontline primary care staff. 26,27 Within the practical formative evaluation framework, each Lab employs a variety of individual methods, including observational site visits, review of internal organizational documents, interview techniques, and feedback mechanisms.…”

“…26,27 Within the practical formative evaluation framework, each Lab employs a variety of individual methods, including observational site visits, review of internal organizational documents, interview techniques, and feedback mechanisms. 28 Details of the overall study design for both Labs are described elsewhere. 26,27 Methodological similarities enable a collaborative, joint analysis of parallel qualitative data across the two Labs in order to demonstrate transferability of findings and to develop a broad, comprehensive understanding of the challenges facing PACTs nationally.…”

The Critical Role of Clerks in the Patient-Centered Medical Home

“…1,[9][10][11][12] By observing PACTs in the clinic and at training events, and by interviewing staff one-on-one, we developed an understanding of how clerks contribute to care. 1,9,10,13 These observations have provided a basis for our developing and sharing the following key insights and suggestions related to the potential for clerks to improve care quality.…”

“…2,3 In tandem, evaluations of the PCMH have highlighted the transformation of roles and associated PCMH-specific educational needs of clinically trained staff, such as primary care physicians and nurses. 1,4,5 In contrast, attention to the role and training of the nonclinically trained team member-primary care clerks-has been exceptionally scant outside their inclusion in measures of patient satisfaction with telephone and scheduling practices. Social scientists have documented primary care front office staff efforts to reduce patient emotional distress and to advocate for service on patients' behalf in traditional primary care settings, [6][7][8] but to our knowledge there has been no substantive attention paid to the nature and importance of clerks' role under the team-based PCMH model.…”

“…At the heart of the model is the structuring of health care delivery around interdisciplinary teams that promote interprofessional competence and in which team members strive to practice at the top of their professional license or competence. 1 Initial studies suggest that the PCMH model may improve quality of care, lower health care costs through decreases in hospital admissions and emergency department visits, and increase clinician and patient satisfaction. 2,3 In tandem, evaluations of the PCMH have highlighted the transformation of roles and associated PCMH-specific educational needs of clinically trained staff, such as primary care physicians and nurses.…”