May 26, 2016

As Obamacare expands access, clinics use team care to adapt


A health screening clinic in New York City. Photo by Chris Hondros.

When more people are covered, clinics have more patients. Maggie Jones writes that safety net clinics are adjusting, supported by private foundations. 

by Maggie Jones, MPH, associate director, Center for Community Health and Evaluation, Group Health Research Institute

Under Obamacare, millions of Americans are gaining health coverage, which is providing them with access to much-needed care. This is a positive direction for public health. But I also see, every day, how challenging this momentous change is for community clinics.

Maggie Jones

At the Center for Community Health and Evaluation (CCHE), we work closely with people who fund and carry out programs and initiatives to improve community health. Two of our recent partnerships responded to the effects of Obamacare on safety net clinics, which provide treatment regardless of patients’ ability to pay. We evaluated programs that were designed to help these clinics adapt to ongoing health care reform.

Obamacare allows states to expand Medicaid by raising the income cap for receiving this insurance. California took this opportunity to increase health care access to people who struggle to get medical services. Of course, expanded coverage means more patients can seek care, so already busy safety net clinics braced themselves for thousands of new patients. Two private philanthropies in California, Sierra Health Foundation and Blue Shield of California Foundation (BSCF), stepped up to help. The programs they funded are helping clinics deliver care differently, benefiting both patients and staff.

Schedule jockeying and team-based care

Both foundations, starting in 2013, gave grants to community health centers to explore and test  ways to increase capacity. Hiring more doctors and nurses wasn’t an option because of a workforce shortage and limited space, so the clinics had to figure out how to wring more out of their existing resources.

The two foundations supported slightly different approaches: Sierra Health gave grantees operational support, for flexibility in reconfiguring to meet rising demand. In the BSCF program, grant recipients enhanced team-based care, a proven model for increasing efficiency. Team care experts from the MacColl Center for Health Care Innovation at GHRI were partners in the BSCF work. CCHE helped with development, implementation, and ongoing evaluation of both foundation-funded initiatives. Our final evaluation reports are online for Sierra Health and for BSCF.

Even with the differing strategies used by the two foundations, we saw common challenges, solutions, and lessons learned. Many clinics worked hard on more efficient scheduling: reducing no-shows and being more flexible about making appointments. For example, clinics empowered front desk staff to “jockey the schedule”—fill the daily schedule by matching cancelled visits with people requesting same-day appointments.

Team-based care was used to maximize efficiency in the BSCF-funded clinics and some Sierra Health-funded sites. A common strategy of team care is to restructure roles, responsibilities, and workflow so all clinic personnel do as much patient care as possible. We call this “working at the top of their license.” An example is creating protocols and standing orders so nurses can make common medication adjustments. This frees up physicians for more complicated care issues. The good news about these innovations is they are sustainable: they provide ongoing benefits without a lot of additional funding.

Clients, staff, and doctors all win

Team-based care innovations help clinics serve patients better. We also found they have positive effects on clinic employees, by letting them fully use their training and skills. These job changes help health care professionals fulfill their career objectives of engaging in patient care and developing relationships with the people they serve. Since we also noted a perceived increase in patient satisfaction in our program evaluations, these innovations benefit everyone.

I see a trend in these two initiatives and other programs that CCHE has evaluated recently. As we reform health care, providers and staff at safety net clinics will feel overwhelmed with the changes. Our work shows that, with support from sources like Sierra Health and BSCF, clinics can increase capacity and serve both existing and new patients. Clinics do this by delivering care differently, like implementing team care, which is a win for staff and their patients.

2016 Birnbaum Lecture


A shared vision: New perspectives on strengthening social determinants of health

Keynote speaker: Dr. Leana Wen, nationally acclaimed TED speaker and health commissioner for the city of Baltimore.