| Improving Primary Care Team Guide

Publications

Publications

Improving chronic disease care by adding laypersons to the primary care team: a parallel randomized trial

Read about the lay role of Care Guide, developed by AllinaHealth and the University of Minnesota. Care Guides help patients and primary care providers achieve recommended chronic disease care goals, by monitoring and following-up with both patient and provider on progress towards goals. Adair R, Wholey DR, Christianson J, White KM, Britt H, Lee S. Improving chronic disease care by adding laypersons to the primary care team: a parallel
randomized trial. Ann Intern Med. 2013 Aug 6;159(3):176-84.

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Publications

A new corps of trained Grand-Aides has the potential to extend reach of primary care workforce and save money.

Read about the layperson role of Grand-Aide, which has demonstrated positive results on reducing costs while expanding the workforce. Grand-Aides act as nurse extenders, using protocols to guide follow-up with patients via telephone and home visits. Garson A Jr, Green DM, Rodriguez L, Beech R, Nye C. A new corps of trained Grand-Aides has the potential to extend reach of primary care workforce and save money. Health Aff (Millwood). 2012 May;31(5):1016-21. doi: 10.1377/hlthaff.2011.0859. PubMed

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Role featuresJob descriptions, career ladders and other HR materials

Role features

"Share the Care" Assessment of Team Roles and Tasks

This is an example of a planning tool, to assess who is currently doing what tasks in your practice and then who should be doing each task, based on how we learned that LEAP sites define clear roles and responsibilities. Task distribution will vary from practice to practice, but the tool is in the discussion about roles that this worksheet can stimulate. Your practice may be able to redestribute tasks in a way that better fits your workforce and patient needs.

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Role features

Planned Care Coordinator Job Description

Here is the job description of the patient access representative role at one LEAP site, reflecting the responsibilities and skills in patient-facing administrative roles.

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Attribution:

Cambridge Health Alliance–Union Square Family Health
Role features

Care Team Patient Advocate Job Description

Here is the job description of the patient advocate role at one LEAP site, reflecting the responsibilities and skills in patient-facing administrative roles.

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Attribution:

Neighborhood Family Practice
Role features

Community Connector Job Description

Here is the job description of the community connector role at one LEAP site, reflecting the responsibilities and skills in health coaching and connecting patients to community resources.

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Attribution:

Hidalgo Medical Services

LEAP Learning ModuleOther helpful topics included in this website

LEAP Learning Module

Resources on Health Coaches and other lay roles providing patients self-management support

Check out the numerous resources available in the Team Guide topic on self-management support. Roles such as Health Coaches can have a powerful impact on team-based care and patient outcomes. After following this link, refer to steps 3 and 4 for job descriptions and training materials to maximize contributions from layperson roles in providing patients with self-management support.

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Video

Video

Medical receptionist story of reaching out and finding patients

Hear a medical receptionist at one LEAP site describe how her team members rely on her do find and do outreach to patients.

Attribution:

Cambridge Health Alliance - Union Square Family Health

Staff trainingTutorials, training manuals, etc.

Staff training

Motivational Interview Training Materials

Learn about resources for motivational interviewing training, in the LEAP Team Guide module on self-management support (Action Step 3).

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Staff training

Community Connector Monthly Report Training Example

See training materials from one LEAP site, Hidalgo Medical Services, preparing community connectors to document their work in following up with patients after an Emergency Department visit.

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Attribution:

Hidalgo Medical Services
Staff training

Community Health Worker training

This website, from the Washington State Department of Health, provides a free online training curriculum for Community Health Workers. Resources include a training manual and videos of people who have benefited from the training. Training modules encompass organizational skills, documentation skills, assessment skills, service coordination skills, and compiling a case study.

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Attribution:

Washington State Department of Health