Shauna Roberts, MD, CPE, is presenting along with several other quality leaders at an NAPH press event announcing the release of a special safety net-focused edition of the Journal for Healthcare Quality on March 15, 2012.

In our article, Addressing Social Determinants to Improve Health Care Quality and Reduce Cost, in the March/April issue of the Journal for Healthcare Quality, we highlighted several important lessons learned as we implemented the quality improvement approach we developed to better serve our chronically ill patients. Among the most significant – and unexpected – of these was the nature of the workforce needed to best provide care continuity services.

First, we found that the nurses (RN) and clinical social workers (LCSW), who comprised the core care continuity teams, were called on to perform a number of roles and responsibilities that are non-traditional for these professions and required a re-tooling of job descriptions. Their new roles on the team included identifying barriers for patients who were not accustomed to their assistance, problem solving competing challenges and priorities in the dynamic movement of a patient through transitions, to assist patients in addressing a variety of challenges that make it difficult for them to make full use of available healthcare (e.g., lack of transportation, no money for co-pays, difficult home situations, no or low literacy levels making it hard to understand what is expected of them). The teams wrap their services around the patients’ ongoing medical and behavioral health services, working across outpatient clinics and inpatient units as well as outside the health system in the community.

What was different for these RNs and LCSWs? Besides explaining their role to others in the system and pointing out how they could support the work of the patients’ usual medical and social service providers, they had to build a trust relationship with patients, many of whom were disengaged and had not always received welcoming treatment from health systems.

As the project progressed it also became clear that, they were doing tasks that others without their level of training and experience could do. We created two new high functioning administrative assistant positions that are responsible for maintaining telephone contact with patients to remind them of appointments, check up on them when they have not been heard from, and to assist the team members in entering and retrieving data related to the patients they serve.

We also identified a need for a high-functioning Pharmacy Technician (Pharm Tech). Patients in our chronic care initiatives have an average of 10+ prescriptions; so managing to take the right medication at the right time is a major challenge. Under the supervision of a pharmacist, the pharm techs identify any problems the patients have taking medications as prescribed and provide support to address any problems (e.g. cleaning up refills with different doses of the same medication at multiple pharmacies).

We have learned a great deal about the attributes of future team members. They will need to be comfortable with ambiguity and not require much job structure, creative in dealing with situations for which one was not trained, and interest in being part of a high functioning team. We also know that we needed people who are passionate about working with patients and respectful of them; anxious to hear their stories and learn from them; and who will use a strengths-based approach in their work.


Shauna Roberts, MD, CPE
Corporate Quality Medical Director
Truman Medical Centers