Poster Presentations (Group II)

Building a chronic care home for underserved patients with resident providers poses special challenges for academic programs.  By describing the creation of language concordant “teamlets” composed of resident and medical assistant pairings at the UCSF/ San Francisco General Hospital Family Health Center [SFGH FHC], this workshop focuses on the role of healthcare teams in a continuity clinic curriculum.  Using a registry of patients with cardiovascular risk factors, these “teamlets” have focused on improving self-management support and planned visits for patients with limited health literacy and English proficiency. 

In the U.S., the majority of patients with chronic conditions are inadequately treated.  Primary care clinicians routinely experience a lack of time to handle acute, chronic and preventive care.  Quantifying this problem, Ostbye and associates found that for a typical panel of 2500 patients, it would take 10.6 hours per day for a physician to provide good management of common chronic conditions alone.   When caring for underserved patient populations with limited English proficiency and health literacy, clinicians may face additional challenges in chronic care.   Disparities in quality of care for some racial, ethnic and socioeconomic groups of patients with chronic conditions such as hypertension, obesity, and diabetes have been well documented. 

Members of the SFGH FHC team in the California Academic Chronic Care Collaborative, developed and implemented an innovative experiential curriculum within the residency’s continuity clinic.   Notably, this Collaborative team includes residents, medical assistents, health workers, nutritionists, and faculty.  This team developed a registry of 200 FHC patients with coronary artery disease risk factors who were scheduled to transfer to new residents.  Because 56% of total FHC patients [n=38,000] do not speak English as a primary language, language concordant teams were intitiated as an integral part of this chronic care intervention.  The registry patients were therefore assigned to language concordant healthcare teams in which at least one team member can speak the patient’s primary language [English, Spanish, Cantonese or Mandarin.] 

Residents are paired with a health coach, who is a re-trained medical assistant or health worker, to form “Teamlets,” or small teams of two people.  At the beginning of chronic care clinics, these teamlets plan chronic care visits using patient registry data.   To improve self-management support, non-clinician roles are expanded to include tasks previously provided primarily by physicians: checking if patients are taking medications as prescribed, assessing patient understanding using teach-back techniques, and forming collaborative self-management plans for behavioral change in diet or exercise.  The health coaches then follow up with patients between clinic visits by telephone.

This poster will describe the role of language concordant teamlets, emphasizing a focus on patient self-management support.  Evaluation data based on focus groups, surveys and clinical measures will be presented.  Analysis of patient outcomes by language will be analyzed.  Tools used to improve patient self management support will be shared.