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Study: PCPs must delegate some preventive, chronic care


There is one primary care physician per 1,500 Americans, yet most PCPs have panel sizes in excess of 2,000 patients. With no surge in PCP numbers expected anytime soon, a new report suggests a shift from physician-based care to team-based care, with PCPs delegating up to 77% of preventive services to non-clinicians.

“Our nation will need to implement models that reengineer the delivery of primary care and deploy our physician supply in a more efficient manner,” say researchers from the University of California at San Francisco in a new paper titled, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians with Team-Based Task Delegation.” The paper was published in the Annals of Family Medicine in the September/October 2012 issue.

The average PCPs panel size is too large to deliver consistently high quality care, according to the report. Researchers estimated that it would take a PCP nearly 22 hours a day to provide all the recommended care for the average 2,300-patient panel. But decreasing PCPs means panel sizes will continue to rise, especially considering about half of all Americans have at least one chronic condition.

The study highlights two alternative practice models that might hold the key to solving this dilemma. The first model is to reduce panel sizes so physicians can provide comprehensive patient care. Concierge medicine, for example, utilizes panel sizes of 200 to 600 patients. However, without enough PCPs to go around using this type of model, the study determines this model would leave many patients without primary care.

The alternative model, the Organized Team Model, advocates building primary care teams that delegate patient care responsibilities among a healthcare team, allowing the physician to practice high-quality care without a large, but manageable panel size. Screening and performing certain tests should be left to the physician, according to the report, but tasks such as administering immunizations could be delegated to non-clinicians—with the clinicians explaining the services to their patients. All routine preventive counseling could be delegated, the report authors note, freeing up too three-quarters of a PCP’s time.

For chronic disease management, the report recommends that PCPs could delegate 75% of the time spent on chronic cases in good control and 33% of the time spent on patients in poor control. Non-clinicians could provide most of the routine chronic services such as patient education, behavior-change counseling, medication adherence counseling and protocol-based services delivered under standing physician orders.

Overall, this model would allow 77% of preventive care and 47% of chronic care to be delegated to non-clinical staff. All acute care would be provided by physicians, the authors note.

The study does not address the additional staff training that would be needed to prepare non-clinicians to handle additional tasks, or the payment reform that would be needed.

“Such an unprecedented change in both the culture and structure of primary care practice can be accomplished only through a change in clinical mindset, the training on non-clinician team members, the mapping of workflows and tasks, the creation of standing orders that empower non-clinicians to share the care, the education of patients about team-based care, and the reform of primary care payment,” the study authors conclude.

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