Using Clinical Microsystems to Implement Care Coordination in Primary Care

Objective: Care coordination is a core competency for primary care nurses and an essential element of the Patient Centered Medical Home (PCMH) model. Implementing care coordination in primary care is challenging and requires changes in roles, staffing, and culture. Clinical Microsystems are frontline teams of healthcare staff that, when engaged in quality improvement, can make important contributions towards practice redesign. We used a Microsystem team to develop an effective model to integrate nurse care coordinators into a busy primary care center. Methods: A Clinical Microsystem team, supported by an improvement coach, met weekly for one year to develop and test a new nurse staffing model in a large Federally Qualified Health Center. Intervention uptake and impact on workflow was tracked by direct observation of nurses and by measuring volume of nursing visits and virtual contacts. Nurses in a non-participating site with similar characteristics served as a comparison group. Results: The Microsystem team developed and implemented a new nurse care coordination model for their site. The intervention emphasized patient self-management, independent nursing visits, and hospital and emergency room transition support. The nurse care coordinator in this new role managed 335 patients over a nine-month study period. The nurse in this new role spent 276 minutes over two days of observation engaged in direct care coordination work while two nurses at the comparison site spent only 94 minutes and 149 minutes, respectively, over the same time period. Conclusion: Engaging front line staff is an effective way for organizations to make changes in delivery systems, improve quality and spread innovations. In this study, a Microsystem team developed a model to provide key components of care coordination to support PCMH practice redesign at a large community health center.