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Primary care staff and clinician-family relationships are critical elements in efforts to improve quality of care

A growing number of family practice and other primary care doctors are being asked to deliver better quality services with fewer resources. As a result, many practices fall short in delivery of preventive, chronic disease, and mental health services. Hiring primary care staff to meet clinical goals and not just economic goals (collaborative care model) has been proposed as one way to achieve better quality primary care services.

A recent study revealed that family practices often used non-nurses to perform patient care duties, and that staff roles were determined primarily by local needs and physician expectations rather than by education, training, or licensure. A second study found that the current environment does not encourage long-term relationships between physicians and family members that are necessary to develop the kind of family knowledge and connectedness that could improve family health.

These two studies were based on month-long field observations at 18 Nebraska family practices, including observations of 1,637 clinical encounters and in-depth interviews with practice staff and physicians. Both studies were led by Benjamin F. Crabtree, Ph.D., of the Robert Wood Johnson Medical School, and supported by the Agency for Healthcare Research and Quality (HS08776).

Aita, V., Dodendorf, D.M., Lebsack, J.A., and others. (2001, October). "Patient care staffing patterns and roles in community-based family practices." Journal of Family Practice 50(10).

Family practices employ a broad range of nursing and non-nursing staff, including registered nurses, licensed practical nurses, certified medical assistants, radiology technicians, and trained and untrained medical assistants. Each profession requires tailored educational preparation for specific patient care roles. However, according to this study, the responsibilities given to patient care staff often were not tied to professional training, and many non-nurses were cross-trained to perform patient care.

The staffing patterns among the 18 family practices studied varied greatly, with most practices employing at least one registered nurse (10 of 18), licensed practical nurse (5), or both (4). Nevertheless, the majority of practices used non-nursing personnel as the predominant patient care staff. Competitive health care market forces may have led many practices to seek less expensive help to provide patient care. This could have resulted in many traditional nursing roles being performed by non-nursing patient care staff, whose training was too limited in scope to enhance and contribute flexibly to recommendations for collaborative care, according to the researchers.

Family practices should formalize expectations of staff to reflect training and experience and explicitly configure staff to meet the needs, values, and goals of the practice, suggest the researchers. In this study, only two practices had strategic matching of staff with the goals of the practice. Most of the practices tried to get by with the minimum educational preparation and number of staff members, which seems to be tied to economic returns. Clinicians should heed collaborative care models that recommend enhancing quality of care by hiring staff trained to meet clinical goals and not just economic goals, conclude the researchers.

Main, D.S., Holcomb, S., Dickinson, P., and others. (2001, October). "The effect of families on the process of outpatient visits in family practice." Journal of Family Practice 50(10).

This study demonstrated that physician knowledge of family context gained from the care of multiple family members over time improves the quality of medical decisions. The current environment does not encourage long-term relationships between physicians and family members that are necessary to develop the kind of family knowledge and connectedness shown by the physicians observed in this study, note the researchers. They found that family context clearly affected outpatient visits at the 18 family practices studied.

In many ways, the doctor treated the family, not just the patient. For example, one doctor took the opportunity to discuss the effect of a mother's smoking habit and passive smoke on her infant, who had developed asthmatic bronchitis. In another case, knowing that a patient's child had died in a car accident enabled a doctor to make the connection between a patient's not taking his heart medications and depression over his daughter's death. Thus, the physician was able to counsel the patient appropriately.

Of the 1,600 patient encounters analyzed, 58 percent were family-oriented in some way. Patients were accompanied during 35 percent of all outpatient visits, with the vast majority of these visits involving children. Family history or a family member's problems were discussed during 23 percent of all visits, even when no family member was present.

By analyzing these "family-oriented" visits, the researchers identified six ways that family context informed and affected the outpatient visit: 1) illuminated patient disease, illness, and health; 2) helped identify the source of a patient's disease; 3) focused attention on the health and illness of family members; 4) demonstrated family concern for a patient's health; 5) involved the family as a care resource and care collaborator; and 6) prompted a family member to receive unscheduled care.

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