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Objective:Increased demand for quality primary care and value-based payment has prompted interest in implementing primary care teams. Evidence-based recommendations for implementing teams will be critical to successful PA participation. This study sought to describe how primary care providers (PCPs) define team membership boundaries and coordinate tasks.Methods:This mixed-methods study included 28 PCPs from a primary care network. We analyzed survey data using descriptive statistics and interview data using content analysis.Results:Ninety-six percent of PCPs reported team membership. Team models fell into one of five categories. The predominant coordination mechanism differed by whether coordination was required in a visit or between visits.Conclusions:Team-based primary care is a strategy for improving access to quality primary care. Most PCPs define team membership based on within-visit task interdependencies. Our findings suggest that team-based interventions can focus on clarifying team membership, increasing interaction between clinicians, and enhancing the electronic health record to facilitate between-visit coordination.

Research Objective Patient continuity of care (CoC) with a primary care (PC) provider is associated with improved outcomes, particularly for medically complex patients. Given the difficulty for a single provider to deliver all services required to the patients on his/her panel, PC providers often provide care to each other’s patients, or “share” common patients. This patient sharing, or interdependence, is not well described, and its impact on patient CoC is unknown. Objectives include the following: (a) To describe PC provider (PC physician, physician assistant [PA], or nurse practitioner [NP]) interdependence (the extent to which patients on a provider’s panel are served by other providers within the practice) and (b) to evaluate the association of patient and panel characteristics, including PC provider interdependence, on patient CoC. Study Design This patient‐level cohort study used electronic health record data from 26 health system‐affiliated PC practices in central North Carolina. Patients’ usual PC provider was the provider most frequently seen during 2016. Patient‐level variables (demographic, medical complexity, and PC utilization variables) were used to calculate panel level variables [panel size, visit number, and provider interdependence (# shared patients / # supplemental providers)]. We examined the association of patient CoC (% of PC visits with usual PC provider) with all variables simultaneously using binomial regression with clustering by practice. Postestimation margins of CoC were calculated using delta method standard errors for a complex patient based on age, number of chronic conditions, and number of PC visits for a complex patient (80‐year‐old woman with ≥ 9 chronic conditions and 43 PC visits) and less complex patient (55‐year‐old man with two chronic conditions and four primary care visits). CoC was calculated for each patient on panels with a range of values (minimums, maximums, and/or means) for panel level variables. Population Studied Adult patients with diabetes (N = 19 957). Principal Findings PC patient panels (N = 164) were led by physicians (N = 134), NPs (N = 20) and PAs (N = 10). Panels for physicians were larger (mean = 131) than NP (mean = 80) or PA (mean = 80). Thirty‐nine % of patients had a visit with a supplemental provider. Panels were served by a mean of 7.6 providers (PCP + supplemental providers), with a mean interdependence of 7.3 patients/supplemental provider. Patient‐level CoC ranged from 6% to 99%. Panel characteristics affected the CoC of complex patients (6‐98%) more than less complex patients (61‐99%). CoC values of the complex patient were lowest when on small panels (6%‐27%) for all provider types. Higher interdependence reduced CoC for complex patients, but improved CoC for less complex patients. Conclusions Patient characteristics and panel characteristics affect patient CoC. Complex, high utilizing patients are at greater risk of low CoC, particularly if they are on small panels that are served by many providers. Less complex patients experienced acce...

Research Objective Quality of diabetes care delivered to patients with different types of usual providers of care [i.e., physician, physician assistant (PA) or nurse practitioner (NP)] is similar. However, primary care (PC) providers often provide care to each other's patients (i.e., “share” common patients). The impact of patient sharing, or interdependence, is on quality of diabetes care is unknown. As a result, some providers and organizations hesitate to formalize patient sharing by creating multi‐provider teams due to concerns about the impact of impact of such teams on quality of care. We sought to both 1) evaluate the association of usual provider type (physician or PA/NP) provider and 2) interdependence on outcomes for patients with diabetes. Study Design This patient‐level cohort study used electronic health record data from 24 health system‐affiliated PC practices in central North Carolina. Patients' usual PC provider was the provider most frequently seen during 2016 and 2017. Patient‐level independent variables included demographic, medical complexity, and healthcare utilization (separate variables for PC, specialty, emergency department, and hospital). Provider panel‐level variables [usual provider of care type (physician or PA/NP), panel size, and provider interdependence (# shared patients / # supplemental providers then categorized into quartiles)]. We examined the association of diabetes quality (at least two hemoglobin A1c (HbA1c) tests, at least one low‐density lipoprotein (LDL) cholesterol test, mean HbA1c and LDL values) during 2017 with all variables simultaneously using logistic or linear regression with clustering by practice. Population Studied Adults with diabetes (N = 10,498) on 131 panels (physician = 111; PA/NP = 20). Principal Findings Ninety percent of patients had physicians as usual providers (N = 9462). Patient demographics, complexity and utilization were similar for patients of different usual provider types except for mean age (physician = 64.6; PA/NP = 59.7) and insurance type (% Medicaid/uninsured: physician: 5.5; PA/NP: 11.2). Most patients had at least two HbA1c tests (72%) and one LDL test (65%). Average HbA1c (7.5 mmHg) and LDL (109 mg/dL) was also similar by usual provider type. Average panel size was 80 diabetes patients (physician = 85; PA/NP = 52) Panels had a mean interdependence of 6.1 patients/supplemental provider (physician = 6.2; PA/NP = 5.8). There were no statistically significant differences in HbA1c or LDL testing by usual provider type or interdependence. Similarly, there was no statistically significant difference in HbA1c for mean HbA1c values by usual provider type or interdependence. However, increases in interdependence quartile resulted in increases in mean LDL values (β = 13.8, p = 0.016). Conclusions The quality of diabetes care does not differ based on provider type, either PA/NPs or physicians. Increases in provider interdependence (greater numbers of patients per provider) resulted in higher mean LDL values, but only the interdependence values in...