Allegheny Health Network (AHN) has been on a multi-year journey to transform its primary care offices and enhance team-based care.
AHN has 120 primary care sites across greater Pittsburgh and the Lake Erie region that serve as the foundation for its patient care delivery. Over the past few years, AHN has been working on a change management initiative to deliver more coordinated and personalized patient care.
Working in a phased approach, the network has invested millions of dollars in optimizing staffing models and processes that make it easier for patients to access care and for providers to deliver it.
“We're taking each provider and making them more efficient in the number of people they can care for, and we're doing it in a way where the quality goes up and the waste goes down,” said Dr. Bill Johnjulio, chairperson of the Allegheny Health Network, Primary Care Institute who led the initiative. “That's what primary care transformation is all about.”
How AHN is building a team-based care model
AHN began its process by creating a core care team model for the practices. Each team member has a defined role in providing care. A nurse is responsible for care management and care navigation. A medical assistant efficiently rooms patients, captures relevant information and alerts the clinician to any needs. A health coach was added to each care team. The health coach is a medical assistant (MA) or a licensed practical nurse (LPN) focused on ensuring patients get screening exams. The health coach also handles pre-visit planning and leads huddles making sure care is coordinated and necessary information is available prior to the visit. That way, primary care physicians (PCPs) and patients can make medical decisions during the visit, rather than by phone when results come back.
With the core care team in place, each office was asked to designate transformation champions: one staff member and one provider in each office to serve as the leaders for the transition. These individuals worked with change management experts to create and implement new workflows focused on team-based care and quality improvement, including pre-visit planning, care management and roles and responsibilities.
Every office takes the transformation concepts and customizes them for their team and practice. That customization is the key to success, Johnjulio said. “When they figure it out — not you — it’s sustainable.”
The next part of the transformation involved creating extended care teams, including clinical pharmacists, behavioral health consultants and registered dieticians who are available on-site or through virtual consultation. “Every time you send referrals out to specialists, the cost goes up and the care is less coordinated," Johnjulio said. “So, we added extended care team members who can get the offices to the next level.”
The addition of behavioral health consultants (BHCs) gives PCPs a resource for helping patients with mental health issues, which often keep people from caring for themselves, and increased the number of mental health screenings.
“Each physician can only care for so many patients if they’re by themselves,” Johnjulio said. “If you get their office functioning at a higher level supported by a team, they can now care for a greater number of patients in a more coordinated manner.” This model has proven to help improve quality and patient outcomes while reducing wasteful health care costs.
Improving patient outcomes
With the transformation of its primary care offices nearly complete, Johnjulio said AHN is seeing positive outcomes on every metric. Admissions to the emergency room and hospital are down, screenings for depression are up, patient engagement with their care plan is increasing, and practices' scores from the Medicare STARS program are higher.
One noteworthy example of the improved quality is in mental health. Before AHN added extended care teams with BHCs, Johnjulio said there was around a 10% chance a patient with a mental health referral would schedule an appointment with a provider, complete a visit and follow up. AHN is now finding that patients referred to a BHC through a “warm hand-off” have over a 45 to 50% engagement rate at the end of a year.
“It’s been a massive game changer,” he said. “Giving practices an advanced or extended care team to help better manage patients and keep them in their office has accelerated the improvement in quality. It’s also improved patient, staff and provider satisfaction.”
Reducing burnout among health care workers
Patients aren’t the only ones benefitting from the new model, Johnjulio said. The team approach makes practices run more smoothly and with less stress, making for better — and sometimes shorter — days for everyone who works there.
Health care workers were feeling strained prior to Covid-19 and the pressure the pandemic put on nurses, physicians and others only increased the problem. In May, U.S. Surgeon General Dr. Vivek Murthy issued an advisory calling health worker burnout a crisis, pointing to a projected shortage of more than 3 million low-wage health workers in the next five years and nearly 140,000 physicians by 2033.
The recommendations in Murthy’s report include transforming workplace culture to empower health workers, reducing administrative burdens and investing in public health — all elements of the AHN approach.
“Doctors are burned out,” Johnjulio said. “They're struggling to get through their day, so we have to do something different to put a little more joy and satisfaction back into their practice.”
Being part of an effort to improve outcomes for patients and health care workers is powerful, he said. “I would say this is probably one of the top three initiatives I have been fortunate to be involved with that has brought satisfaction in defining a career.”
From infants to seniors, everyone enjoys better health when they have access to a reliable primary care physician. At AHN, you can see your PCP in-person or online. Learn more about primary care at AHN or get connected to a PCP by calling 412-DOCTORS (412-362-8677).
Allegheny Health Network, a Highmark Health Company, is a western Pennsylvania-based integrated healthcare system that serves patients from across a five-state region that includes western Pennsylvania and the adjacent regions of Ohio, West Virginia, Maryland and New York.
Lauren Lawley Head is a freelance writer for The Business Journals Content Studio.
