A large rural federally qualified health center (FQHC) in Maine seeks to increase access to and quality of care through decreasing variability in efficiency and panel sizes among its primary care teams across 5 of 17 sites through spread of a "delegate model." Secondary objectives are to enhance provider and team job satisfaction, increase team function, and decrease provider and staff burnout.

1. TAKING EFFICIENCY TO SCALE: Spread of a Delegate Model in an FQHC
Susan Grantham, PhD., MPP1
, Noah Nesin, MD2
, Natalie Truesdell, MPH, MBA1
, Eugenie Coakley, MPH1
and Sarah Genetti, BA1
,
(1) John Snow, Inc. (JSI), Boston, MA, (2) Penobscot Community Health Care, Bangor, ME
BACKGROUND/PURPOSE
A large rural federally qualified health center (FQHC) in Maine seeks to increase
access to and quality of care through decreasing variability in efficiency and
panel sizes among its primary care teams across 5 of 17 sites through spread of
a “delegate model.” Secondary objectives are to enhance provider and team job
satisfaction, increase team function, and decrease provider and staff burnout. A
dyad of primary care providers (PCPs) is assigned a “care team medical assistant
(CTMA)” to enhance the clinical team (from two MAs to two MAs plus a CTMA).
The CTMAs are receiving enhanced training to take on higher level tasks to reduce
administrative burden on providers, including comprehensive pre-visit planning,
inbox management, schedule management, and patient referrals. Study questions
are:
• How was spread strategy implemented?
• To what extent was the intervention adopted among provider teams and sites?
• Does the model result in improved efficiency?
• Does the model result in improved provider satisfaction and team functioning
and less burn out?
• What are the estimated costs of implementation?
• What contextual factors influence each of the above questions?
METHODS
This study employs a multistage mixed methods approach comparing
implementing teams with non-implementing teams over three years in
the domains of efficiency metrics, spread strategy, assessment of team
perceptions, cost and unintended consequences.
CHART 1: Provider
and Medical
Assistant Burnout
in November 2014
(Baseline)
I enjoy my
work. I have
no symptoms
of burnout.
Occasionally
I am under
stree at
work, but
I don’t feel
burned out.
I have one
or more
symptoms
of burnout,
such as
physical or
emotional
exhaustaion.
The
symptoms of
burnout that
I’m experi-
encing won’t
go away.
I think about
frustations
at work a lot.
I feel
completetly
burned out
and often
wonder if
I can go on.
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Provider
MA
4.2%
8.7%
33.3%
47.8%
50.0%
39.1%
8.3%
0.0%
4.2%4.3%
CHART 2: Spread
Strategy and
Implementation
Timeline
Too little time
The right amount of time
Too much time
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Engaging in direct
patient care
32%
64%
4%
56%
44%
0%
12% 12%
76%
12%
16%
72%
Engaging in
patient teaching/
counseling/
education
Documenting to
the electronic me-
dial record (EMR)
Completing
paperwork
CHART 3: Provider perception
of appropriate time management
November 2014
DOES THE MODEL RESULT IN IMPROVED SATISFACTION AND TEAM FUNCTIONING?
Initial efficiency metrics showed: For a 15 month period, across 5 prac-
tice sites all cycle times fell in a range of 32 minutes to 90 minutes. At
each practice cycle time averaged 52 – 55 minutes. The early results of
the first implementation team showed some increased efficiency with
an average cycle time of 46:34.
PRIMARY CARE PERSPECTIVE MEDICAL ASSISTANT PERSPECTIVE
“I have noticed a huge reduction in my desktop
workload since my MA started more aggres-
sively managing it. In addition, her comments in
the banners and screening of labs helps me pri-
oritize which ones need more immediate action.
WOW! This has been by far the project with the
most positive impact on me personally anyway.”
“Patients seem to love it, because they are see-
ing the gaps in care being taken care of even
at the non preventive care visits, we take the
opportunity to get things done.”
“In a recent discussion the first delegate team
site was identified as a site which has made
significant progress in quality metrics and this
was attributed to the initiative. Again, it is now
accepted among executive leadership at PCHC
that the benefits of this approach justify the
costs and there is a strong desire to spread.”
“This model should relieve provider
stress and make sure no patients fall
through the cracks.”
“Prior to the delegate model we were
scrambling to get things together for
the provider the day a patient was be-
ing seen. Now we look ahead a week or
two, and I can have everything prepared
for the providers to view.“
“Think all patients deserve this level of
pre-visit planning and attention to en-
sure the preventive services are provid-
ed. Recommend it across the organiza-
tion and to other organizations.”
Stage 1
Jan 2014 - Dec 2014
Implementation in “Champi-
onship teams” in 5 sites
Positive and observable
outcomes
Intense training and TA
intense experimentation and adaption of DM
Positive and observable
outcomes
Spread to majority of teams
in all sites
Continued training and TA
Sites take over some training and TA DM model stabalizes
Stage 2
Jan 2015 - Dec 2015
Adopted as PCHC practice
model
Sites take over training and TA
DM model becomes ptractices norm
Stage 3
Jan 2016 - Dec 2016)
DOES THE MODEL RESULT IN IMPROVED EFFICIENCY?
PROVIDER STRESS
ORGANIZED PREVENTIVE
CARE
IMPROVEMENTS
IN QUALITY