Team-Based Care: A Critical Element of Primary Care Practice Transformation

Abstract

The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming their practice to deliver patient-centered care. The study used qualitative research methods to conduct case studies of small primary care practices in the state of Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents 3 team-based care models that were utilized by the practices in this study. (Population Health Management 2013;16:150–156)

Introduction

T he United States health care system is plagued with countless problems, many of which stem from the fragmented and decentralized structure for delivering and paying for care. Although primary care is seen by many as the foundation of a well-functioning health care system, it has not received a high degree of attention with regard to advances in care delivery mechanisms and reimbursement for services. In fact, the US health care system falls short in many ways when considering Starfield's definition of primary care as the patient's first contact with the health system, continuity of care with the same provider, comprehensive care, and coordination of care across health system components.¹ System problems related to primary care include a reimbursement system that pays for procedures and episodes of care, and a culture that has a high regard for high-tech specialized services. Within primary care itself, there are increasing numbers of patients with chronic illnesses, declining access to services, dissatisfaction among current practitioners, and decreasing numbers of new practitioners entering primary care specialties. In addition to these issues, the Patient Protection and Affordable Care Act of 2010 expands insurance coverage to millions of uninsured individuals by the year 2014, which is expected to dramatically increase the demand for primary care services.^2,3

Redesign of the primary care sector is necessary to improve access, quality, and patient experience. Efforts to redesign the delivery and financing system include pilot projects to test the feasibility of accountable care organizations, which are reimbursed, in part, on patient outcomes and overall savings. Other efforts are aimed at the development of new models of care delivery at the practice level, with the most prominent being the chronic care model (CCM) and the patient-centered medical home (PCMH) model.^4,5 Characteristics of these models include a focus on population health management involving intensive care management for high-risk individuals, coordination of care between providers, performance measurement, improved care delivery processes, and methods to support patient self-management of care. Health information technology, such as electronic health records (EHR) and decision-support systems, also are critical components of these models.

Application of the CCM or PCMH model at the practice level requires additional activities, beyond those associated with the provision of traditional primary care, related to care coordination and population management. These models are deeply rooted in the notion that team-based care will result in the greatest improvement in health outcomes for patients.⁶ The definition of a team, in this sense, is a group of diverse clinicians who participate in and communicate with each other regularly about the care of a defined group or panel of patients.⁷

A large body of evidence exists on the role of team-based care in improving patient safety, patient-centeredness, and health outcomes in primary care settings. Team-based care is an especially important facilitator of patient safety. Several studies found that communication problems between providers accounted for a large majority of adverse outcomes and medical errors, while others have demonstrated that team-based quality improvement interventions significantly reduced the number of preventable adverse drug events.^8,9 Furthermore, the use of multidisciplinary teams has been associated with reduced medication errors, improved medication adherence, and fewer inpatient hospital days. Additional evidence suggests that multidisciplinary teams can help facilitate patient self-management support following events that require hospitalization. Several studies have noted that, as a result of interventions focused on team-based care delivery, both hospital readmission rates and cost of care were reduced for chronically ill patients.^10
–12 Other studies confirm the effect of team-based care on health outcomes for patients with chronic disease. Collaboration between nursing, pharmacy, and medical professionals has resulted in significant reductions in both systolic and diastolic blood pressure.^13

–17 Similarly, team-based care interventions for patients with diabetes have demonstrated achievable improvements in cholesterol levels, blood-glucose levels, blood pressure, and body mass index (a measure of obesity).^18,19

In addition to improvements in clinical outcomes, team-based care models resulted in increased productivity for providers of chronically ill patients, allowing health care professionals to see more patients, as well as provide more comprehensive care for patients with complex health needs.²⁰ Team-based care models are also effective in improving the patient experience in primary care settings. Results from evaluations of existing team-based care models suggest high satisfaction rates for both patients and physicians.^21,22

Despite evidence that team-based care can improve quality, patient experience, and provider satisfaction, the adoption of team-based care in private practice has been slow. Although many studies have evaluated the outcomes of team-based care, there is a dearth of information on the structure and functioning of successful team-based care models, which could help other practices adopt approaches suitable for their needs. This article presents in-depth case study research and examines the structure and use of team-based care in 3 primary care practices.

Methods

Study design and sample

The original goals of this study were to examine quality improvement efforts and performance of 8 primary care practices in the state of Virginia using qualitative research methods. The study addressed a multitude of transformation efforts, including the use of health information technology (IT), patient engagement, innovative scheduling mechanisms, care coordination methods, and functional office space.

This 2-year project, from 2009 to 2011, included 16 months of field work during which more than 90 on-site interviews with practice clinicians and staff and 36 structured telephone interviews were conducted. Physicians, nurses, medical assistants, practice administrators, and quality improvement specialists were interviewed for this project. The study also utilized document reviews of policies and performance reports, and observation of staff meetings, team functioning, and individual interactions. Practice sites for study participation were identified based on data obtained from a previous survey of primary care practices in Virginia on the existence of PCMH model components.²³ A purposeful sampling approach was used to select practices for study participation based on a maximum variation of practice location, ownership, and the existence of the following quality improvement activities: team-based care, performance measurement, health IT, and use of evidence-based guidelines. The study was approved by the institutional review boards at George Washington University and Virginia Commonwealth University. All study participants signed a consent form.

The goals of the study were to understand what quality improvement efforts practices were undertaking, to examine how these activities were incorporated into their practices, and to identify results of improvement activities. After closely examining the 8 practices over a 2-year period, team-based care was recognized to be the most critical element of primary care practice transformation. This realization led to a more careful examination of the successful team-based models used by practices in this study. Successful team-based models were defined as those used by practices that were able to demonstrate improved quality of care through performance measurement and/or a high level of patient satisfaction and loyalty. Another key finding from the study was that clinical leaders have varying preferences and face different environmental conditions and, therefore, need a multitude of options to consider for practice transformation.

Study objectives

This portion of the study highlights 3 primary care practices with team-based care models to describe the details of each model, including team composition and functioning. All 3 practice sites were small, with the number of physicians ranging from 1 and 6; utilized an EHR; maintained a team-based care model; and offered programs and services to boost employee satisfaction and morale. All 3 practices excelled in patient service and physician and employee satisfaction. Characteristics of the 3 practices described in this study are listed in Table 1.

Table 1.

Characteristics of Primary Care Practices Using Team-Based Care

Characteristics	Case A	Case B	Case C
Location	Suburban	Urban	Rural
Ownership	Health system	Health system	Independent – physician owned
Practice age	30	3	25
Physicians	1	6	6
Nurse practitioners or physician assistants	0	2	0
Nurses (RN, BSN, LPN)	3	7	8
Medical assistants	2	0	2
Average number of patients seen per provider per day	35	30¹	25
Average patient panel size	3,500	2,700²	3,450
Electronic health record	Yes	Yes	Yes
Open access scheduling³	Yes	Yes	Yes
Clinical performance measurement	Yes	Yes	No
Productivity and financial measurement	Yes	Yes	Yes

Physicians see 30 patients per day; nurse practitioners see 22 patients per day.

Average number of active patients seen by providers; inactive patients not counted for this practice.

Same day appointments for urgent and non-urgent appointments.

Data collection

Data collection methods included the use of on-site visits involving recorded interviews, document reviews, and observation of care processes, patient flow, and interactions between individuals, including clinicians, administrative staff, and patients. Physicians, nurses, medical assistants, practice administrators, and quality improvement staff were interviewed; examples of interview questions are displayed in Table 2. Interviews were audiotaped and transcribed for data analysis. The Virginia Family Medicine Practice Survey and the National Survey of Physician Organizations also were used to collect information from practices on the structure and functioning of the practice, finances, quality improvement efforts, and organizational culture.^24,25

Table 2.

Examples of Interview Questions

What do you see as the most important purpose of your practice? What are the most imperative activities you have to do in order to achieve that purpose?

Can you describe what it is like to work in this practice – the general atmosphere, how people communicate and get along, how they deal with conflict?

Can you tell us how your practice is organized to deliver care?

Can you explain the roles and responsibilities of each team member?

Can you describe the patient flow in your practice, from when the patient first enters the building to when they leave after completing their visit?

Describe the process you have for ensuring continuity of care for patients.

Describe your practice's relationships (formal or informal) with other specialists in your community.

What do you believe are barriers or areas for improvement to ensure continuity of care for your patients?

Explain what changes the practice made in order to improve performance.

What are the major external and internal factors that motivated you to undertake these performance improvement efforts?

Data analysis

Qualitative data analysis involved coding transcriptions of interviews using NVivo software (QSR International Pty Ltd, Doncaster, Victoria, Australia) to identify themes within and across cases as well as unique attributes and experiences. The research team used 3 phases of coding. The first, open coding, involved examining the transcript text and developing categories or themes of information. This involved a constant comparative method of identifying instances that represent the category. In the second phase, axial coding, the team sought to interconnect the categories. The third phase, selective coding, involved identifying themes across cases.²⁶

Validity and reproducibility of findings were aided by primary review of transcripts followed by secondary review, triangulation of data from different sources, semi-structured interview guides, and maintenance of an audit trail of code development. Data collection and analysis was conducted by a multidisciplinary research team to draw from different perspectives and experiences. The team consisted of individuals with expertise in primary care medicine, nursing, mental health, management, and qualitative research methods. The analysis and findings were vetted by an external auditor with extensive experience in qualitative health research.

Results

Across case findings

Three team-based care models emerged from the case study research of primary care practices in Virginia. These models represent various methods to organize a team to deliver primary and preventive care. Each of the team-based care models operates in conjunction with the use of an EHR and other technology to support data collection and information retrieval for patient care delivery, tracking patient care needs, and coordination of care. All team-based care models require some level of change in the roles and responsibilities of individual professionals, as well as additional training in the use of health IT and expanded clinical functions such as engaging patients in self-management of chronic illnesses. These practices also have well-established relationships with various specialty providers in their communities, which is essential for coordinating care for patients.

Organizational culture was shown to be a critical aspect of a true “team” care model. Team-based practices all exhibit similar cultural characteristics including: shared responsibility, respect for diversity of skills and knowledge of team members, an open environment in which to raise concerns and make suggestions, an emphasis on comprehensive patient care and quality improvement, and team member willingness to take on additional roles and responsibilities. Providers and staff also have a high degree of loyalty to the practice.

Within case findings

Case A—Top of license team model

In this model, team members work at the top of their professional licenses to care for a panel of patients. A patient panel is a group of patients who get most of their primary care from a given clinician. The team is comprised of a physician, 2 nurses, a patient referral clerk, and administrative staff. The physician is responsible for the physical exam, data analysis, decision making, and care plan development. Nurses are responsible for data gathering and entering most patient care information into the EHR, as well as care plan implementation and patient education. A patient referral clerk coordinates referrals, including scheduling appointments, and entering consult reports into the EHR.

Nurses are given a substantial role in collecting data from the patient during the visit, presenting patient problems to the physician, entering the treatment plan into the EHR during the physician exam, reviewing the plan with the patient, and providing patient education after the physician leaves the exam room. The nurse collects a substantial amount of information from the patient, including the history of present illness, a review of past problems and treatments, a targeted systems review, a list of medications and side effects, a social history, and a preventive care update. Nurses are trained to ask disease-specific and symptom-related questions of patients such as questions about chest pain, cough, and abdominal pain. Once the preliminary data are collected from the patient and entered into the EHR system by the nurse, the physician enters the exam room, and then the nurse reports out the information to the physician and the patient. The nurse remains in the exam room and updates the patient's electronic chart during the physician visit. Finally, nurses review with the patient any follow-up and disease management issues that were discussed with the physician, and deliver a written treatment plan to the patient. At the end of the day the physician reviews, updates, and signs the patient's chart.

Nursing staff work at the top of their license, which in turn allows the physician to focus on cognitive aspects of diagnoses and treatment and to focus complete attention on the patient during the exam. This model maximizes the knowledge and capability of nursing staff, allows the physician to focus his or her time on patient care activities, and provides the patient with an enhanced opportunity to interact with clinical staff.

Although this model required additional nursing staff and training for nurses, it allowed the practice to increase its patient population significantly, generate additional revenue, and improve the patient's experience and quality of care. The physician and the nurses reported to the research team a considerable increase in job satisfaction under this model. Results regarding quality of care, patient satisfaction, and financial outcomes data supporting this model have been widely reported in previous publications. For example, the physician went from seeing 22 to 23 patients per day to seeing 35 to 40 patients per day. This, in turn, increased his gross revenues from less than $400,000 to $580,000 per year. Patient experience surveys were very positive, with 96% of patients reporting that they would recommend the practice to others.^27
–29 Quality of care also improved, with an increase of blood pressure control and low-density lipoprotein cholesterol control from approximately 70% in 2002 to almost 85% in 2007.³⁰

Case B—Care coordinator model

The care coordinator model is designed for population management whereby additional effort is concentrated on managing patients who are high risk, high complexity, and/or those with high utilization of health care services. In this model, the care team consists of a provider (physician, nurse practitioner, or physician assistant), a nurse, a care coordinator, and administrative staff, all of whom work together to care for a panel of patients. Each care team holds a morning huddle to discuss patients who have high-risk issues and complex chronic diseases. All team members have access to and share responsibility for data entry into the EHR.

The care coordinator, typically a nurse, works for multiple providers and patient panels. The care coordinator has 2 main tasks: coordination of patient transitions in care and population management for high-risk, high-complexity patients. Tasks involved in ensuring effective transitions in care include calling patients who have been discharged from the hospital or emergency department to coordinate ongoing care. Population management involves identifying patients with poor disease control from a patient registry and encouraging them to be seen by a provider. The care coordinator conducts disease coaching with patients with a specific level of poor disease control, which includes providing health education and patient self-management support. The care coordinator explores barriers to self-management and setting goals with patients at each coaching session. This approach allows a more concentrated effort to engage high-risk patients in self-management activities. Care coordinators received additional training in coaching and are now certified as “chronic care specialists.” The practice used a “Train the Trainer” style chronic disease coaching education course, which included 2 days of didactics and role-play followed by online disease education modules.

During the patient visit, a nurse or medical assistant places the patient in an exam room and collects and records basic information, such as vital signs and the reason for the visit, in the EHR. Nurses perform higher functions such as administering EKGs and immunizations and identifying patient needs and deficits in care. The nurse also reviews the patient chart for core preventive care needs such as mammograms and pneumococcal vaccines. The nurse may perform mini-assessments of the patient; for example, cognitive or mobility assessment. Outside the office visit, the nurse is responsible for answering phone calls from patients, medication refills, arranging prior authorizations, and completing forms.

During the exam, the provider focuses on taking the history, assessing symptoms, conducting the physical, assessing the need for consultant referrals, interpreting test results, reviewing medication issues, and prescribing new medications. The physician enters data into the EHR on patient progress notes and laboratory and diagnostic testing orders. How the provider and nurse function as a team depends on how much the provider “trains” his or her nurse. In the past, the provider dealt with all chronic and acute issues, which was difficult to change during transition to the care coordinator model.

Refinement of the care coordinator model is an ongoing process as the practice encounters new problems and tries to make the model more efficient and effective. The practice recently scaled back the number and role of care coordinators because of financial difficulty in supporting this model with no reimbursement from payers for additional activities associated with population management and care coordination. Implementation of the team-based care coordinator model increased the practice's mammography screening rates from 37.2% to 70.46% and their diabetic blood pressure control from 39.2% to 71.96% over a 3-year period (2009–2012). (In November 2011, the practice changed the diabetes mellitus blood pressure control from 130/80 to 140/90 to reflect the current standard of practice.)

Case C—Enhanced traditional model

This multidisciplinary, high-functioning team model is an enhanced version of the traditional model whereby the physician performs the majority of patient care during the visit. The team consists of physicians, nurses, medical assistants, and front office administrative staff. Nurses and medical assistants are assigned to a specific physician, unless unusual circumstances arise. All team members are responsible for retrieving and entering data into the EHR related to their assigned roles and responsibilities.

During a typical patient visit, the patient enters the office and checks in with the front desk staff and provides up-to-date demographic and health insurance information. The nurse pulls the patient record information from the EHR and reviews the chart to determine preventive care needs, such as immunizations and medication refills. The nurse escorts the patient to the exam room and checks vital signs, collects basic information on the reason for the visit, and questions the patient on their general health, symptoms, and other issues. The patient encounter with the nurse and physician include the history and physical examination. Parts of the history include the chief complaint, history of present illness, review of systems, allergies, medical and surgical history, family history, lifestyle habits, and medication review. The reason for the visit determines which components of the history and physical need to be assessed during the encounter and the level of interaction between the patient and clinical staff. For patients with specific diseases and those on specific therapeutic regimens such as warfarin, the nurses maintain a registry of patients for ongoing care coordination to ensure completion of necessary testing and follow-up encounters.

Although this practice engages in fewer activities related to population health management than other team-based care models, it provides a high level of services to meet patients' needs. These services include open access for urgent and nonurgent appointments, and available weekend and night visits. The practice has strong relationships with specialty providers in the region, and administrative staff assist patients to obtain referral appointments with specialists, including mental health practitioners. The physicians in this practice even started a free clinic, separate from the medical practice, for patients without health insurance coverage.

At this practice, the team is high functioning because they work together for the common goal of providing the best possible patient care services. Defined roles and responsibilities for each team member and effective communication and trust between individuals are important. The use of EHR task lists and reminder lists by staff are critical for communication and for effective handoffs between team members. This high-functioning team model has an embedded organizational culture that reflects an emphasis on patient-centered care, reliability, willingness of team members to take on additional responsibilities when needed, and shared responsibility for patient care—similar to the organization culture found in the 2 team-based care models presented earlier. Team members help each other, do what it takes to get the job done to meet patient needs, and work together to be the best provider in the community. Physicians, nurses, and administrative staff reported high personal satisfaction rates with this model, low patient turnover, as well as patient self-reported satisfaction. Because the practice does not currently collect clinical performance data, quality of care for this model could not be assessed during the study.

Discussion

Implications

Given the potential addition of 32 million more Americans having some form of health insurance in the next several years, combined with the aging of the population and the current decline in the primary care workforce, it is essential to understand practice structures that create greater capacity for care while improving quality of care. Although the 3 models discussed in this study had some variation in roles and responsibilities, all represent a step away from the “doctor does it all” approach. This approach might have worked when acute care was the focus of primary care physicians, but is woefully inadequate to attend systematically to preventive services and chronic disease management, much less population health care.

It is incumbent upon health services researchers to continue to examine what team-based care models are most effective, what makes it possible to create and sustain these models, and how effective models can be disseminated to the majority of primary care practices in the United States. This is particularly important for independent practices, which generally have less access to expertise and capital to assist them to transform their practices into more efficient and effective models.

The challenges identified by practices in this study point to the need for new forms of payment for team-based care activities such as care coordination and population management, as well as “extension agent” services to provide guidance to primary care providers to incorporate new technologies and care delivery mechanisms into their practices. The extension agent model has been used for decades in the United States agricultural sector to transform farming practices by employing a local community member to serve as a consultant and coach to local farmers. Primary care could benefit from a similar model of community-based health extension agents to educate providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health services, evidence-based therapies and techniques, quality improvement techniques, and practice transformation. Although included in the Patient Protection and Affordable Care Act of 2010, the primary care extension agent program has yet to be funded. Local and state policy makers should be working with academic units, professional societies, and commercial payers to create mechanisms to transform existing primary care practices into more robust models.

As Chen and Bodenheimer⁷ pointed out, a critical element of team-based care is sharing responsibility for the health of a panel of patients, which will allow clinicians to lead a team rather than individually see one patient after another. The findings of the current study suggest that team-based care can help primary care practices manage increasing workloads. Team-based care models also can help practices meet the needs of complex and high-risk patients, engage staff in meaningful work, and improve patient, provider, and employee satisfaction. This study points to the need for the identification and dissemination of information on various types of team-based care models, which will provide options for clinicians to consider when designing a care model that best suits their needs and preferences.

Dissemination of team-based care information to practices may best be accomplished by professional associations and other organizations focused on improving quality of care at the practice level. This study also suggests that practices interested in implementing a team-based care model must focus on defining new roles and responsibilities, providing opportunities for training in new roles, establishing communication mechanisms, changing organizational structure and care processes, and involving employees in the change process.

Footnotes

Author Disclosure Statement

Drs. Goldberg and Kuzel, Ms. Beeson, Ms. Love, and Ms. Carver disclosed no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acknowledgment

This research was funded by the US Department of Health and Human Services, Agency for Healthcare Research and Quality Grant R01HS018422.

References

Starfield

. Is primary care essential? Lancet, 1994; 344:1129–1133.

Elmendorf

. Letter from the Congressional Budget Office to the Honorable Nancy Pelosi, Speaker, US House of Representatives on an estimate of the direct spending and revenue effects of H.R. 4827 Reconciliation Act of 2010 (Final Health Care Legislation) http://www.cbo.gov/doc.cfm?index=11379. 2010 April 9.

Hofer

, Abraham

, Moscovice

. Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization. Millbank Q, 2011; 89:69–82.

Wagner

. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract, 1998; 1:2–4.

Patient-Centered Primary Care Collaborative (PCPCC). Joint principles of the Patient-Centered Medical Home. http://www.pcpcc.net/node/14. 2011 November 6.

Coleman

, Austin

, Brach

, Wagner

. Evidence on the chronic care model in the new millennium. Health Aff (Millwood), 2009; 28:75–85.

Chen

, Bodenheimer

. How do we get to the primary care of the future? Adopting a team care approach. http://www.ihs.gov/california/uploadedfiles/gpra/BP2011_AdoptingACareTeamApproach%28Chen%29.pdf. 2011 November 2.

Bates

, Leape

, Cullen

et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA, 1998; 280:1311–1316.

Fernald

, Pace

, Harris

, West

, Main

, Westfall

. Event reporting to a primary care patient safety reporting system: A report from the ASIPS Collaborative. Ann Fam Med, 2004; 2:327–332.

10.

Rich

, Beckman

, Wittenberg

, Leven

, Freedland

, Carney

. Multidisciplinary intervention to prevent the readmissions of elderly patients with congestive heart failure. N Engl J Med, 1995; 333:1190–1195.

11.

Kaboli

, Hoth

, McCLimon

, Schnipper

. Clinical pharmacists and inpatient medical care: A systematic review. Arch Intern Med, 2006; 16:955–964.

12.

Naylor

, Brooten

, Campbell

, Maislin

, McCauley

, Schwartz

. Transitional care of older adults hospitalized with heart failure: A randomized controlled trial. J Am Geriatr Soc, 2004; 52:675–684.

13.

Bogden

, Abbott

, Williamson

, Onopa

, Koontz

. Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension. J Gen Intern Med, 1998; 13:740–745.

14.

Borenstein

, Graber

, Saltiel

et al. Physician-pharmacist comanagement of hypertension: A randomized, comparative trial. Pharmacotherapy, 2003; 23:209–216.

15.

McLean

, McAlister

, Johnson

et al.

A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: Study of cardiovascular risk intervention by pharmacists-hypertension (SCRIP-HTN)

Arch Intern Med, 2008; 168:2355–2361.

16.

New

, Mason

, Freemantle

et al. Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): A randomized controlled trial. Diabetes Care, 2003; 26:2250–2255.

17.

Schneider

, Larrimer

, Visconti

, Miller

. Role effectiveness of a pharmacist in the maintenance of patients with hypertension and congestive heart failure. Contemp Pharm Pract, 1982; 5:74–79.

18.

Pape

, Hunt

, Butler

et al. Team-based care approach to cholesterol management in diabetes mellitus: A two-year cluster randomized controlled trial. Arch Intern Med, 2011; 171:1480–1486.

19.

Scanlon

, Hollenbeak

, Beich

, Dyer

, Gabbay

, Milstein

. Financial and clinical impact of team-based treatment for Medicaid enrollees with diabetes in a federally qualified health center. Diabetes Care, 2008; 31:2160–2165.

20.

Bray

, Roupe

, Young

, Harrell

, Cummings

, Whetstone

. Feasibility and effectiveness of system redesign for diabetes care management in rural areas: The eastern North Carolina experience. Diabetes Educ, 2005; 31:712–718.

21.

Kanter

, Martinez

, Lindsay

, Andrews

, Denver

. Proactive office encounter: A systematic approach to preventive and chronic care at every patient encounter. Perm J, 2001; 14:38–43.

22.

Rosser

, Colwill

, Kasperski

, Wilson

. Progress of Ontario's family health team model: A patient-centered medical home. Ann Fam Med, 2011; 9:165–171.

23.

Goldberg

, Kuzel

. Elements of the patient-centered medical home in family practices in Virginia. Ann Fam Med, 2009; 7:301–308.

24.

Goldberg

, Mick

. Medical home infrastructure: Effect of environment and practice characteristics on adoption in Virginia. Med Care Res Rev, 2010; 4:431–449.

25.

Rittenhouse

, Casalino

, Gillies

, Shortell

, Lau

. Measuring the medical home infrastructure in large medical groups. Health Affairs (Millwood), 2008; 27:1246–1258.

26.

Cresswell

. Qualitative Inquiry and Research Design: Choosing Among Five Traditions, 2nd. Thousand Oaks, CA: Sage Publications, 2007.

27.

Anderson

, Halley

. A new approach to making your doctor-nurse team more productive. Fam Pract Manag, 2008; 15:35–40.

28.

Kuehl

. PCMH Profile. Team-based care leads to financial success. http://www.aafp.org/online/en/home/publications/news/news-now/pcmh/20090217anderson-q-a.html. 2011 September 22.

29.

Terry

. An effective way to use assistants: Training nurses and MAs to take histories and provide patient education boosts productivity, income, and quality of care. http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?ts=1320960919648id=443727. 2011 November 11.

30.

Anderson

, Halley

. A new approach to making your doctor-nurse team more productive. Fam Pract Manag, 2008; 15:35–40.