How it Works in a Practice
Primary Care Associates (PCA) is a three-clinician practice located in a suburban area. PCA has an office manager and four additional full-time staff members. One person is dedicated to the front desk operations, and three of the staff members are medical assistants.
Staff of Primary Care Associates:
- Senior Physician, David Smith
- Nurse Practitioner, Kesari Singh
- Physician Partner, Nicholas Swanepoel
- Medical Assistant, Tracy Hoover
- Medical Assistant, Rosa Sanchez
- Medical Assistant, Meghan Meade
- Front Desk, Mary Reed
- Office Manager, Kim Machenski
Through this case study we discuss the challenges, identification of potential solutions, and outcomes of several issues that would typically come up in such a practice.
During a lunch break on a Thursday in January, nurse practitioner Singh and Dr. Swanepoel discussed how they have each seen three patients this week with bad coughs––some caused by bronchitis and others related to the flu. They were frustrated that many of the patients with coughs were smokers. Dr. Smith walked in and overheard some of the conversation and asked them what they said to these patients about their smoking. Nurse practitioner Singh said that she didn’t address the smoking because she knew that the patients wouldn’t stop—she said she’s tried getting patients to stop but it never works. Dr. Swanepoel said he reviewed the patients’ medical histories, pointed out that smoking makes coughs worse and advised them all to quit. He didn’t think that the advice was particularly useful––most of the patients were either quiet or dismissive, and one said to him “I know, I know, I don’t need another lecture.”
Dr. Smith was concerned their practice wasn’t really dealing with the behavior problems that lead to many of the physical illnesses they treat. He reached out to an old classmate from medical school who was a psychiatrist at a nearby hospital to ask about places they could refer patients with nicotine addiction and other addictions. She provided him with the names of a few tobacco-cessation classes and groups as well as some outpatient alcohol and drug abuse programs in the area. However, she also recommended that the staff members change their approach from ignoring problem behaviors or simply giving advice to an approach called motivational interviewing (MI). She gave Dr. Smith reading material on the approach. He was convinced that the practice should be trained to incorporate MI into patient care.
Dr. Smith first took a CME course on MI and then held a meeting to discuss the integration of MI into the practice. He provided a brief overview of the approach and said that they would be introducing new office policies and procedures to work with patients who can benefit from some health behavior changes. Dr. Smith summarized the evidence base on using MI to improve health by decreasing unhealthy behaviors including alcohol, drug and tobacco use, poor diet, lack of exercise, and poor medication adherence. Practice members welcomed new ideas and training on how to better help patients whose behaviors harm their health, but also expressed concern about implementing a new approach to treating and engaging with patients. Dr. Swanepoel was concerned that he didn’t have the skills to use MI effectively and that it would be difficult to learn. Tracy Hoover, Rosa Sanchez, and Meghan Meade wondered how this applied to them because they don’t talk to the patients about their medical problems much at all. All members of the practice were concerned about the extra time this new approach might take.
What Did the Practice Do?
Dr. Smith identified five major areas (discussed below) that need to be addressed to effectively use MI in their practice. He stressed the importance of making a commitment to learn about and use MI. Nurse Practitioner Singh agreed to act as the MI team leader (“champion”) and to research several clinical practice guidelines to identify recommendations and policies that could be incorporated into the practice. The medical assistants agreed to work together to promote a patient-centered, nonjudgmental atmosphere in the practice.
Conduct Staff Training on MI
- Dr. Smith arranged a half-day paid training on a Saturday for staff members to learn about the philosophy of behavior change, stages of change, and principles of MI. Staff members participated in role play exercises and discussed challenges to using MI in patient encounters.
- He contracted with the MI trainer to return and do monthly booster sessions during lunch breaks and to also train any new staff members.
Implement MI as part of usual, ongoing care
- Nurse practitioner Singh volunteered to adapt the medical history form to include reliable and valid health screening questions about alcohol, tobacco, and drug use; nutrition and healthy diet; physical activity; medication adherence; and chronic disease management.
- All staff members discussed how to incorporate MI into the work flow of the practice and developed policies based on these discussions.
- All staff members agreed on the following work flow for delivery of MI: collect information on medical history form; follow up of screening responses, including assessment of importance, confidence, and readiness to change; and brief MI-based discussion and summary (conducted by physician or nurse practitioner).
Document MI practices in patient medical records
- The office manager, Kim Machenski, modified the patient medical record system to include documenting MI results such as readiness to change; confidence in ability to change; stage of change; and reported pros and cons to a particular problem behavior.
- All staff members agreed that it would be useful to also track how a patient is doing over time and share those results in staff meetings to see if patients’ stage of change or readiness increases over time. They planned to look at specific patients who they were concerned about as well as an aggregate reporting of overall improvement in their patients.
- They also decided to track referrals to treatment and resources provided so they could follow up with patients about the referral to ensure the patients’ overall well being.
Share information and resources
- The medical assistants researched and chose posters, brochures, and other materials on common behaviors needing change to provide in waiting and exam rooms.
- They also developed physical and electronic binders with lists of agency and provider referrals (e.g., substance abuse providers), helplines (e.g., smoking cessation or problem drinking), and support groups (e.g., diabetes management or exercise groups) so that all staff members had easy access to referral sources.
Monitor and track MI delivery and conduct ongoing quality assurance
- During monthly staff meetings, clinicians and staff members discussed challenges and successes with MI, noted any changes in patient health behaviors after MI, and reviewed charts to ensure MI techniques were being employed effectively.
- On a quarterly basis, the practice staff agreed to shadow each other on a specified day during three patient visits to monitor MI implementation. Staff will discuss the results at the next staff meeting to learn from each other and enhance practice MI implementation. This allows the practice to work together and create an MI peer support group.