Overview

The health service delivery model is rapidly changing. The integrative and collaborative team approach is becoming the model for the future. This will be especially true for development of primary care sites in underserved areas. Competition for primary care givers will be one of the driving forces dictating the service delivery model chosen for your community. In this chapter we discuss service delivery models and the key factors which will help to define the appropriate model for your community.

SERVICE DELIVERY MODEL

Traditionally, the health care delivery system was structured in a medical model, oriented to illness care provided by physicians. Other primary care practitioners served in a variety of supportive, surrogate or collaborative roles. Today, the trend is toward an interdisciplinary team approach which includes physicians, physician assistants (PAs), nurse practitioners (NPs) and certified nurse-midwives (CNMs), as well as dental and behavioral health providers. This integrative and collaborative team approach has arisen in response to:

• the shortage of primary care physicians and dentists;
• the increase in the supply of nurse practitioners, physician assistants and certified nurse-midwives;
• the total quality management movement which stresses team interaction;
• the move toward a health and prevention model of care; and
• the need to find cost-effective approaches to delivery of care.

As you go through the planning process for the development of your center, give serious consideration to developing an interdisciplinary team model for meeting the primary care needs of the community. Nurse practitioners, certified nurse-midwives and physician assistants provide high quality, cost effective care with high levels of patient satisfaction. The Office of Rural Health Policy has cited a number of reasons for the increased use of NPs, CNMs and PAs:

• The quality of care provided by these practitioners practicing within their scope of practice was equal to that provided by physicians. In selected areas such as management of long-term patients or labor and delivery, the quality may even surpass that typically provided by physicians;
• NPs, CNMs and PAs in collaboration with physicians can provide 60-80 percent of the care provided by primary care physicians and 90 percent of that provided by pediatricians;
• NPs, CNMs and PAs have a greater initial and ongoing career commitment to practice in underserved areas when compared to physicians; and
• NPs, CNMs and PAs have less preparation time and financial costs than physicians which means that they can provide a more immediate and less costly solution to the need for primary care practitioners.

If you are interested in learning more about interdisciplinary primary care models, you may first wish to contact some of the Federally-supported health centers in your state, since most of them in both urban and rural locations, employ a combination of NPs, CNMs, and/or PAs to supplement the primary care capacity of their medical staff. To locate a nearby Community Health Center, go to the following Web site, http://findahealthcenter.hrsa.gov/ where you can search by address, state, county, and click "Find a Health Center." If you are contemplating the development of a rural site only, you are advised to contact the National Association of Rural Health Centers at http://www.narhc.org. Rural Health Centers (RHCs) are required by statute to employ NPs, CNMs, and/or PAs at least 50% of the scheduled hours during which RHC services are provided. Additionally, it is recommended that you visit the following Web site for an excellent overview of interdisciplinary models of team practices: http://dcahec.gwumc.edu/education/session3.

You may recall from Chapter 2 that nine examples of various practice models were briefly described to illustrate the wide variety of organizational arrangements possible for delivering primary care. Authors of the book, Prescription for Primary Care - A Community Guidebook believe that the choices can be narrowed down to three basic models as follows: (1) Private Practice, (2) Practitioner/Community Partnership, and (3) a Community Corporation. The relative advantages and disadvantages to each approach are discussed in greater detail in Exhibit 7-1. Communities struggling with questions and issues of how to develop the most appropriate approach tailored to their particular situation are encouraged to study the potential tradeoffs for each model carefully in order to assist them in making the right choice.

DETERMINING YOUR STAFFING NEEDS

The most important resources of any organization are its human resources - the people who supply the organization and the community with their work, talent, creativity and commitment to primary care. Among the critical functions to be performed in the establishment of your center will be the determination of the number and type of staff needed. It goes without saying that without competent people, the organization will not be able to pursue or achieve its goals.

Your staffing needs will be directed by the goals set during the planning process and the specific needs of your community. These goals are based upon the needs of the population to be served, the current health status, the availability of existing services and the finances available for service provision.

Even with specific goals and objectives, staffing is a complex function consisting of a number of sequential and interdependent steps:

• clarifying the scope and volume of primary care services to be rendered in the community;
• determining which types of primary care practitioners should be used to provide the care (e.g., for obstetrical care, can you justify a family practitioner, an obstetrician/gynecologist, a certified nurse-midwife, a combination of these practitioners complemented by a nurse practitioner, and physician assistant);
• predicting the number of each type of personnel needed to provide the planned services;
• determining the role of students;
• recruiting and selecting personnel to fill the vacancy;
• arranging staff into the desired configuration; and
• assigning responsibilities for care and service provision.

The matrix below can be used as a worksheet to determine the number of full time equivalents (FTE) needed to be recruited.

Matrix to Determine the Number of Health Care Providers
(FULL TIME EQUIVALENTS)

FACTORS TO CONSIDER IN DETERMINING STAFFING

There are several variables that need to be taken into account when determining your staffing needs and arrangements. Some examples of staffing factors considered by Barnett and Mayer in their textbook - Ambulatory Care Management and Practice are outlined below:

• Type of community - the size of the community, financial considerations and past experience will be important factors when determining your staffing needs.
• Type of patient - the patient population will determine the type of practitioners needed to deliver the services to be provided at the site.
• Volume of patients - the larger the clinic in terms of patients seen the greater the number of clinicians, administrative personnel and support staff needed.
• Complexity of patients - the more complex the patient the more likely the need for a higher skill level of personnel. For example, simple immunizations may be handled by a nurse; whereas, unstable diabetes may require the knowledge and skills of a nurse practitioner or physician.
• Physical design of the facility - some facilities are designed in such a way that staff may be shared - for example, an assistant in close proximity to the front desk can cover the reception area in busy times. Other facilities, because of their design, may not be able to share staff.
• Ability and skill level of staff - the higher the level of staff expertise, the easier it is to establish a more efficient, flexible staffing pattern. If licensure restrictions permit, cross training can help to keep costs down. For example, an office medical assistant can answer phones, make appointments, take cash, and find charts.
• Support activities - the more services provided, the more infrastructure is needed to support the services. This leads to a more complex organization and a greater need for personnel. Even if support services are not provided at the site, if available in the community they will increase the amount of interaction which occur between health care entities. This interaction will require personnel time and staff.

STAFFING PATTERNS

Planning the staffing of a primary care project must be done carefully. If overstaffed, a project's costs will outstrip its receipts. If understaffed, patients' needs cannot be met. Experience has shown that, even in communities largely without health resources, people have established ways of meeting their health problems. (When a new resource of care is established, it may take some months, and sometimes years, before people change from their established source of health care.) A plan for staffing can be predicated on some valid assumptions even though it will take time to reach maximum utilization of health personnel.

Sample health personnel-to-population ratios for beginning primary care projects are set forth below. These ratios take into consideration the lower initial demands by the population for health care services through the new project. Utilization of the project by a greater number of the population increases as the project's time in existence increases.

Please note that the above population range/staffing pattern ratios do not represent utilization by 100% of the target population - they are just rough guides to illustrate a magnitude of possibilities. In order to develop a more realistic forecast of your particular staffing needs, it is suggested that you again review the market analysis methodology outlined in the previous chapter, Exhibit 6-4. Once you have estimated a high vs. low range of potential unmet need (e.g., potential gaps) for primary care service encounters in your service area, you should then be able to convert these numbers to a range of desired primary care FTEs using a ratio of 4500 encounters per primary care physician provider per year. These estimates may be further refined by applying the appropriate staffing ratios, productivity, and utilization rates noted in Exhibit 7-2 which is based on recent Uniform Data System (UDS) reports for the year 2002. In conducting this exercise, you should also keep in mind that most health centers today did not start with the same level of staffing they have today - rather they grew over time as resources permitted. You may find that you will need to follow a similar pattern of development.

In the final analysis, the staffing pattern for your site will depend of a variety of factors such as those noted on page 7-4. In addition to the non-profit sector staffing ratio, encounter utilization rate guidance outlined in Exhibit 7-2, you may also wish to consult the American Medical Association (AMA) at http://www.ama-assn.org and/or the Medical Group Management Association (MGMA) at http://www.mgma.com for comparable staffing guidance from the private sector model with little or no community oversight. An additional source of private sector planning data is available from the Practice Management STATS Quick Reference Guide which may be purchased at a modest cost from http://www.practicesupport.com. Whatever service model you choose or whatever staffing pattern you may propose, you are encouraged to work closely with your local providers and practice management resources to develop realistic staffing plans that are best suited for your particular project.