The role of delegation in promoting enhanced clinic access in medical homes: perspectives from primary care providers and nurses in the Veterans Health Administration

True JG, Stewart GL, Lampman MA, Pelak M, Solimeo SL. The role of delegation in promoting enhanced clinic access in medical homes: perspectives from primary care providers and nurses in the Veterans Health Administration. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 23; Baltimore, MD.

Research Objective: An emerging literature has documented barriers to enhancing clinic access in the context of Medical Home implementation. To date, organizational factors have been emphasized, while internal team-focused barriers to practice redesign have been less well-described. Our research objective was to understand and describe barriers to implementing enhanced clinic access from the perspective of Primary Care Providers (PCPs) and Registered Nurse Care Managers (RNCMs) working in the Veterans Health Administration (VHA). Study Design: The study was part of a multi-year, mixed-methods formative evaluation of VHA's transformation to a Patient Aligned Care Team (PACT) model across two Veterans Integrated Service Networks (VISNs). Semi-structured interviews conducted during the first 18 months of PACT implementation elicited information regarding strategies for practice redesign, roles and expectations for different team members, and challenges arising during implementation. Interview transcripts were coded separately for the two VISNs, with a focus on identifying themes around barriers to enhanced clinic access from the perspectives of team PCPs and RNCMs. Themes identified for each VISN were then compared for similarities and differences to develop a comprehensive understanding of the challenges facing PACTs across two large and diverse geographic regions. Population Studied: Purposefully sampled PCPs (n = 32) and RNCMs (n = 42) implementing PACT in the upper Midwest and mid-Atlantic regions. Principal Findings: Reported strategies for achieving enhanced clinic access were relatively standard across regions and teams. To be successful, these strategies required negotiation of team roles, interprofessional understanding, and reallocation of work. PCPs reported constraints on their ability to delegate, expressed uncertainty about nurses' scope of practice, and stressed the importance of within-team decision making with regard to daily team activities. RNCMs described feeling unsure about role expectations, voiced frustration with PCPs' perceived unwillingness to delegate, and highlighted the challenges of acquiring new responsibilities with limited delegation power. State-by-state variations in laws governing scope of practice for RNs contributed to further concern and confusion about what work could be done by team nurses. Conclusions: At the team-level, PCPs and RNCMs are the primary drivers of practice change necessary to achieve enhanced clinic access. In order to make and sustain such changes, they require support in a number of key areas including: clear guidance on scopes of practice for different team members that reflect local conditions; tools to improve role clarity (e.g., customizable position description templates); and methods for enhancing intra-team functioning and communication (e.g., close support from local practice coaches). Ideally, these resources would be made available at the earliest stages of Medical Home implementation. However, teams already engaged in implementation activities who are struggling with enhanced clinic access would still benefit from guidance and resources. Implications for Policy, Delivery, or Practice: Prior evaluations of Medical Home implementation have described macro-level factors affecting practice improvement efforts, such as payment reform and organizational culture. In contrast, this study emphasizes team-level impediments including challenges to interprofessional role negotiations and delegation of work. Unaddressed, these issues may lead to increased stress and burnout for primary care staff, and ultimately scuttle organizational initiatives to make meaningful changes to delivery of care.