title: Teamwork and delegation in medical homes: primary care staff perspectives in the Veterans Health Administration.
abstract: BACKGROUND
  The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential.
  
  
  OBJECTIVE
  To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation.
  
  
  METHODS
  Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States.
  
  
  METHODS
  A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates.
  
  
  METHODS
  Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation.
  
  
  RESULTS
  We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation.
  
  
  CONCLUSIONS
  Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.
authors.affiliation: VISN 4 Center for Evaluation of Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs Medical Center, Building 4100, University and Woodland Aves, Philadelphia, PA, 19104, USA, Jennifer.True2@va.gov.
authors.forename: Gala
authors.initials: G
authors.lastname: True
authors.forename: Greg L
authors.initials: GL
authors.lastname: Stewart
authors.forename: Michelle
authors.initials: M
authors.lastname: Lampman
authors.forename: Mary
authors.initials: M
authors.lastname: Pelak
authors.forename: Samantha L
authors.initials: SL
authors.lastname: Solimeo
mesh_terms: D006282:Health Personnel / Q000458:organization & administration*; D006801:Humans; D010348:Patient Care Team / Q000458:organization & administration*; D018802:Patient-Centered Care / Q000379:methods / Q000458:organization & administration*; D032024:Personnel Delegation / Q000458:organization & administration*; D010865:Pilot Projects; D011320:Primary Health Care / Q000379:methods / Q000458:organization & administration*; D014481:United States; D014493:United States Department of Veterans Affairs / Q000458:organization & administration*
references.citation: Am J Manag Care. 2009 Sep 01;15(9):e71-87
references.pmid: 19728768
references.citation: J Gen Intern Med. 2013 Apr;28(4):539-45
references.pmid: 23192447
references.citation: Mil Med. 2012 Dec;177(12):1445-7
references.pmid: 23397685
references.citation: Ann Fam Med. 2012 Sep-Oct;10(5):396-400
references.pmid: 22966102
references.citation: Ann Fam Med. 2010;8 Suppl 1:S57-67; S92
references.pmid: 20530395
references.citation: Arch Intern Med. 2011 Mar 14;171(5):460-6
references.pmid: 21403043
references.citation: Health Aff (Millwood). 2012 Sep;31(9):2002-9
references.pmid: 22949449
references.citation: Health Serv Res. 2012 Dec;47(6):2273-95
references.pmid: 22670806
references.citation: Health Serv Manage Res. 2012 May;25(2):51-9
references.pmid: 22673694
references.citation: Med Care. 2011 Jan;49(1):10-6
references.pmid: 21079525
references.citation: Health Aff (Millwood). 2010 May;29(5):874-9
references.pmid: 20439874
references.citation: Health Aff (Millwood). 2008 May-Jun;27(3):w232-41
references.pmid: 18445642
references.citation: Gerontologist. 2012 Oct;52(5):703-11
references.pmid: 22421916
references.citation: Health Aff (Millwood). 2013 Feb;32(2):294-302
references.pmid: 23381522
references.citation: Health Care Manage Rev. 2004 Apr-Jun;29(2):129-38
references.pmid: 15192985
references.citation: J Gen Intern Med. 2010 Jun;25(6):584-92
references.pmid: 20467907
references.citation: J Interprof Care. 2015 Jan;29(1):26-33
references.pmid: 25052920
references.citation: Nurse Pract. 2012 Apr 15;37(4):33-9
references.pmid: 22430928
references.citation: Ann Fam Med. 2007 Sep-Oct;5(5):457-61
references.pmid: 17893389
references.citation: Health Aff (Millwood). 2009 Jan-Feb;28(1):64-74
references.pmid: 19124856
references.citation: Am J Manag Care. 2013 Jul 01;19(7):e263-72
references.pmid: 23919446
references.citation: Am J Manag Care. 2012 Feb;18(2):105-16
references.pmid: 22435838
references.citation: Milbank Q. 2012 Sep;90(3):484-515
references.pmid: 22985279
references.citation: Ann Fam Med. 2012 Mar-Apr;10(2):169-73
references.pmid: 22412010
references.citation: J Gen Intern Med. 2012 Aug;27(8):992-1000
references.pmid: 22798211
references.citation: Am J Manag Care. 2013 Feb;19(2):132-40
references.pmid: 23448110
references.citation: Ann Fam Med. 2009 May-Jun;7(3):254-60
references.pmid: 19433844