Teamwork Among Primary Care Staff to Achieve Regular Follow-Up of Chronic Patients

Although studies have shown that more temporally regular (TR) primary care visits are associated with improved patient outcomes, none have examined what clinic staff can do to encourage greater TR visits. This study aims to increase understanding of factors related to health care staff dynamics that contribute to more TR primary care visits for adults with chronic health conditions.

We conducted semistructured interviews with 15 primary care physicians, 12 nurses, 15 administrative staff, and 4 pharmacists at 12 clinics; one-half characterized as high-TR clinics where patients had regular follow-ups, and the other as low-TR clinics. Interviews were audiotaped, transcribed, and coded using Atlas qualitative data analysis software (Lumivero, LLC).

Themes emerged regarding best ways to promote regular follow-up of patients with chronic conditions. These strategies included having a system to encourage follow-up (beginning with administrative staff reaching out to patients and ending with recruiting the help of patients' family members), routine staff meetings, adaptive workflow, dealing with bureaucracy on patients' behalf, informal channels of communication with patients, and consulting social workers. Clinics with more regular follow-up emphasized teamwork, a peaceful approach toward challenging patients, and flat as opposed to hierarchical organizational structures for personal relationships among staff.

Teamwork between staff members in primary care settings can contribute to more proactive care delivery, with greater potential to prevent long-term complications. The findings suggest that a high-functioning multidisciplinary care team that focuses on creating the right sorts of interactions and teamwork among members of the staff can contribute to engaging patients more effectively.