The team approach to home-based primary care: restructuring care to meet individual, program, and system needs

Area of Science:

• Geriatrics
• Primary Care
• Healthcare Management

Background:

• Home-based primary care (HBPC) is crucial for managing complex medical and psychosocial needs of homebound individuals.
• Existing HBPC models may face challenges in scalability and physician workload.
• Quality improvement initiatives are essential for optimizing healthcare delivery.

Purpose of the Study:

• To evaluate the impact of restructuring a physician-led academic HBPC practice into a team-based model.
• To assess changes in patient care metrics, patient satisfaction, and physician well-being.
• To explore an innovative approach for enhancing interdisciplinary care in HBPC.

Main Methods:

• A quality improvement project involving the restructuring of an academic HBPC practice.
• Integration of an office-based nurse practitioner, a dedicated social worker, and an administrative assistant to support physicians.
• Comparison of pre- and post-restructuring data on patient panel size, hospitalizations, readmissions, and satisfaction.

Main Results:

• Physician panel size increased significantly.
• Physician satisfaction improved post-restructuring.
• Hospitalizations, readmissions, and patient satisfaction levels remained consistent.

Conclusions:

• Team-based care models can enhance efficiency and physician satisfaction in HBPC.
• Practice restructuring with dedicated support staff is a viable strategy for managing larger patient panels.
• This model offers a scalable solution for improving interdisciplinary care for homebound populations.