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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