LaZell Hammons: Multidisciplinary primary care teams

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  • Posted:Wednesday 18 November 2015

Ben Collins talks to LaZell Hammons, Nurse Director of Quality Improvement at Southcentral Foundation, about the 'Nuka' system of care they use in Alaska.

This video was filmed while Ben was in Alaska as part of his research for a report.


BC: So LaZell, you were one of the first Nurse Case Manager’s at Southcentral and you participated in redesigning your multidisciplinary teams. Tell me a little bit about those teams and who does what.

LH: The primary care provider is the one that is overseeing the team, helping to set the plan – they’re the ones that physically see customers when they come into clinic. If they have village assignments, they go out and visit their customers in the villages twice a year, and they’re also monitoring their data to make sure that their outcomes are where they should be. The Nurse Case Manager’s position and role – they are more behind the scenes and they are all co-located in a one area together, an integrated care team; so they sit elbow to elbow to each other. So they’re all within line of sight of each other. The Nurse Case Manager is doing population management; so they’re looking beyond just the customers that are presenting that day in clinic. They’re looking at their whole panel which ranges in size between 1,000 and 1,300 customers. So they’re looking proactively at the needs of their panel. They are looking at the day’s schedule and looking to see if there’s anything that we could do to max pack that visit and then they’re coordinating with the rest of the team to make the plan go smoothly for the customer.

So the Certified Medical Assistant, they’re in a role to the team as far as the… they’re the masters to be able to make sure the flow of the day goes well. So they are the person that is rooming the customer. So at the beginning of the day, our schedules look very different than midday because our goal is that when you look at our schedules across the board at 8am, 50% of our access is open for our customers so that we truly can deliver on same-day access. So they are looking at the schedule. They’re proactively setting the rooms up to anticipate the needs of that visit. They are managing the schedule – so as things change throughout the day, they’re able to inform the staff. So they are notified in our system, our EHR, that a customer is ready and has been checked in at our front desk and they physically go out to our lobby area and invite them to come back for the visit. As they’re coming back, they are doing vital signs – so they’re weighing them and getting their vital signs, and then they have some screening questions that we do for things like depression screening, and then they do their vitals in the room, enter them into the EHR, and then they notify the primary care provider that the customer is ready, and then they’re on about their day to plan for the next one or bring the next customer back.

BC: So how do these primary care teams work with the other specialist staff you have in your integrated care teams?

LH: If there’s someone that has a history of depression, the BHC or the Behavioural Health Consultant may have already looked at that schedule and looked for anything that might cue them into going in on that visit and so they’re already kind of prepared before they would go in on the known items that they would go in for. So the provider would go in after the CMA or Certified Medical Assistant has notified them, they go in, they would see the person and they would come out and tap on the Behavioural Health Consultant to let them know that they’re ready to do a warm hand-off to bring them in. That co-location has broken down so many barriers for us and it’s really built that dynamic of our teams that we are intending, and there’s some magic that happens in those integrated care teams because of that proximity.

So we have what’s called a data mall and it’s an online tool that has a gooey interface that people are able to access – readily access their data, specific to their panels – I mentioned our panel sizes are between 1,000 and 1,300 generally speaking. So you’re able to look at that data and say, “This is my data, these are customers that come to us to partner with for their care, and I’m able to reach out to them proactively,” and of that 12%, it lists their name, date of birth, if it’s a kiddo it lists who the guardian is and their phone number and so it makes it easy for me to do the right thing as a clinical person.


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