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The Primary Care Team

  • Patient panel is supported by a robust clinical team with augmented nurse staffing for all visit and non-visit work.
  • Some APCs co-manage patients with primary primary care clinicians affirming their role in sharing the total care of the patient and supports longitudinal, high-value relationships.
  • Nurses are empowered to facilitate the care required to manage acute, chronic and preventative health needs.
  • Medical Assistants are engaged in more clinical work with appropriate nursing oversight and supervision.
  • PCPs and APCs can focus on meaningful patient interactions, complex care oversight, and new patient access.

Atrius Health from a PCP perspective

Atrius Health has an organizational focus which is aligned with PCP values

  • Primary care led
  • Value over volume
  • Innovation valued and implemented at the site and organization level
  • Outpatient only – independent of the hospital

Primary care leadership

  • Primary care physician leadership opportunities – service line chiefs and chairs, performance excellence medical directors, Academic Institute/Innovation Center engineers
  • The primary care physician has a leading voice in the practice

Innovation is accessible and technology is embedded in care delivery

  • Automating prescription renewals to increase quality and reduce PCP burden
  • Predictive analytics embedded in Epic and workflows
  • Supportive clinical tools embedded in Epic – SmartRx, SmartLab
  • Collaborations with Healthfinch, Verily and Firefly, etc.
  • Shared Medical Appointments, e-consults, televisits, and home visits are all investments we are committed to

Burnout is an organizational priority

  • Care model supports systems to reduce work burden on the PCP
  • Leadership invested in burnout management strategies
  • Investing in networking events to facilitate community

Team-based care is our model

  • A leader in team based care over the decades – APC teaming, nursing, clinical pharmacy, population managers, case managers, and more
  • Care model investment in advancing team care – pod jams, nursing role in chronic disease, elevating Medical Assistants, revising clinical information flow – we are taking it to the next level

Primary care practice supports that matter

  • Telecom – making on call assignment immeasurably better
  • Urgent care – providing access outside regular office hours and for overflow
  • Anticoag program – providing safety and supporting PCPs in managing high-risk medications
  • Specialties support primary care through e-consults and in-person consults.

Care delivery in the home is a priority for optimal outcomes

  • Home based hospital (Medically Home) has revolutionized how we provide care in the home for our sickest patients.
  • Multiple partnerships with home based programs which deliver full spectrum of care in the patient’s home, such as ED at Home.
  • Organizational commitment to continuously develop new ways of providing care in the home.

Adapting Primary Care to the pandemic

  • Fully integrated video visits in primary care, inclusive of preventative, chronic, urgent and acute.
  • A practicing primary care physician, leads the organization’s efforts in telehealth.
  • Strategic approach to developing future capabilities and flexibilities for in person and video visits.

Process Improvement – we are always seeking a better way that includes all of our workforce

  • Engagement across the organization in changing care
  • Involving multidisciplinary teams in transformation projects
  • Data driven

Collaboration is practiced

  • Cross service line initiatives to develop shared models of care – in BH and primary care, OB/Gyn-primary care
  • Cross service line and strategies to care for chronic disease – CHF, COPD, DM, osteoporosis
  • Supporting primary care work by re-engineering referral systems and supports

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