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Transforming Primary Care – A Call for Team-Based Care

By Kimberly Mitchell | Thursday, May 14, 2015

IHI’s Cindy Hupke, BSN, MBA, is director for IHI's Transforming the Primary Care Practice seminar. In this blog post, Hupke describes how the team-based approach IHI has espoused for over 15 years has become the gold standard as the patient-centered medical home (PCMH) model becomes more prevalent.


I sometimes think about how little time most patients spend with their health care providers. Of the 5,000 waking hours in a year, even a person with a chronic health condition might only spend a few hours with a doctor or nurse over the course of a year. The rest of the time they are on their own, making decisions, following recommendations, motivating themselves to do more exercise or get enough sleep. Consequently, health depends less on primary care or hospitals and more on the patients themselves. We need to think beyond the four walls of our clinics and into the lives, communities, and homes of the populations we serve.

Given how relatively little time we spend with our patients, how can we understand the world in which they live? How do we develop meaningful, continuous relationships with patients when there are seemingly endless needs to meet every day, including acute illnesses, preventive services, chronic disease management, and behavioral health issues?

As I discussed in an interview on transforming primary care last year, part of the answer is in how we organize and deliver care. To provide safe, effective, timely, efficient, and equitable care, we must organize ourselves in highly functional teams, with the engaged patient at the center.

The team-based approach has become more prevalent as the patient-centered medical home (PCMH) model has become a standard to aspire to in many organizations, and the most recent standards place an emphasis on the importance of teamwork. Over the past 15 years, IHI and key partners have been at the forefront of advancing team-based care – not merely so that teams can get recognition or accreditation – but because it improves the patient experience, creates better access, reduces costs, improves flow, and typically results in greater staff satisfaction.

In team-based primary care, doctors, nurse practitioners, physician assistants, nurses, medical assistants, dietitians, pharmacists, social workers, and others function as an integrated team. The goal is for everyone to work to the highest level of their licensure, training, and experience. An optimized care team provides the skills and resources to jointly plan and customize patient care and provide alternative types of visits, as needed. By tailoring their approach to each patient and segment of the population, they can provide support for individuals and families to better manage their own health.

Interactions with patients will continue to take place in the office, but also through “visits” online or over the telephone, or with e-referrals to specialists. This is not simply to cut costs or to address the shortage of primary care clinicians, but because in some circumstances it can be the best way to meet the needs of patients. In a team-based approach, with proper evaluation and assessment of real demand and current supply, patients will be able to get access to primary care when they need it, when they want it, and in the way they want it. There are many challenges to implementing this model – such as reimbursement – yet many organizations are making the proverbial “leap of faith” to do the right thing without waiting for the payment system to catch up with what the system needs to provide for patients.  

We need to think beyond health care and begin to focus on what matters to the patients and community: health and wellness. We cannot achieve this without patient engagement. Primary care teams have the opportunity to develop partnerships with patients and families by involving them fully in approaches that can meet both the medical and behavioral needs of each person. By working together as a team, we can collaboratively develop the kind of high-quality, comprehensive care that no single health professional could provide alone. Go, team!

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