In this Q&A, IHI Director Cindy Hupke explains how organizations can move from talking about team-based care to actually doing it. Hupke is director for IHI's Transforming the Primary Care Practice seminar.
[Photo credit: Susan Young Photography]
Q: After almost two years, your previous interview on team-based care is one of the most popular IHI Blog posts. Why do you think there’s so much interest?
With the ever-changing and complex landscape of health care, it is necessary for organizations to take a hard look at and thoroughly assess the current systems and processes they have in place. Many organizations are hard at work to develop a successful and highly functional team-based approach. In doing so, they are positioning themselves to ensure success in the current era of health care delivery in which there are internal and external demands for increased productivity and access, decreased costs, a focus on improving the person and family experience, and a desire and need to have a healthier population.
Most organizations have identified that, to do this work well, it takes a team. And it might sound simple enough, but developing and sustaining a healthy team takes time, energy, and ongoing nurturing.
The burden on primary care providers continues to grow as they assume responsibility for acute, chronic, and preventive care for an increasing number of patients. If a team of professionals meets the needs of the population — with each team member working to the highest level of their licensure, experience, and training — it will take some of the pressure off the bottlenecks in the system. Ultimately, the system focuses more on safe, timely, effective, efficient, equitable, and patient-centered care and approaches.
More providers are beginning to understand the importance of team-based care, but most have not yet implemented this approach. They have the will to change, but might be lacking pragmatic ideas and approaches and a method to execute those changes effectively in their organizations.
The team-based approach, however, is not without its challenges and barriers as well as its opponents. Generating discussion and welcoming opposing views stimulates great ideas, and will result in new approaches and innovations to the provision of health care and ultimately a healthier population.
Q: What are some challenges hindering organizations in implementing a team-based approach?
First, reimbursement. Many payers do not reimburse for anything other than a physician to deliver certain services. With team-based care, it might be beneficial from many perspectives to offer nurse visits, pharmacist visits, or group visits, and to get reimbursement for those types of visits can be challenging in some states or from some payers. Not every visit requires the services of a primary care physician, and many visits can be better served by another member of the team, like a behaviorist or dietician or pharmacist. Team-based care helps provide the right care at the right time by the person with the most appropriate level of training, experience, and licensure. Reimbursement practices, however, don’t always support this design.
Second, leadership. People really pay attention to what leaders are paying attention to, and, if leaders themselves are cultivating a team-based culture, that will lead to a more team-based approach within the organization itself. In addition, organizational leadership might not understand the effort necessary to develop the team-based philosophy. At Bellin Health in Green Bay, Wisconsin, for example, each employee receives 14 hours of training on team culture. That is a leadership commitment that few organizations might be willing to make. Cultivating teamwork takes time because the vitally important components — such as trust, open communication, vision, participation, cooperation, and sharing — must develop and grow.
Third, greater collaboration and trust. Physicians are highly-trained individuals who typically rely on their own training to make sound decisions and judgment calls. Team-based care requires greater collaboration than some providers might initially be comfortable with. Across the country, the biggest struggles we see and hear about are when physicians don’t trust that another care team member can do a job as well as they do. There might be concerns from the physicians that “their plate is very full,” yet they are often unwilling to let go of some of their responsibilities to others who can perform the tasks within their level of licensure and training. Organizations need to mitigate this issue through small-scale testing, training, observation, and collecting data on processes and outcomes to demonstrate reliability and accuracy of the processes.
Q: Is there a way to test a team-based approach, rather than making the whole shift at once?
Yes, and we strongly encourage organizations to test on a smaller scale initially. Those interested can find a care team conceptual diagram in the Primary Care Team Guide. It is based on Learning from Effective Ambulatory Practices (LEAP) to help practices think about how to organize a care team around the patient. Within this care team diagram, there are three segments:
The core team, which is collectively responsible for a defined patient panel and includes provider(s), a clinical assistant such as a medical assistant, perhaps an RN, Health Coach, etc.;
The extended team, which includes services and resources that might typically be shared among care teams, such as a behavioral health consultant, social worker, or care coordinator; and
The affiliated staff, who are not typically employed by the practice, but are part of the care team through formal links with outside organizations.
Practices could test just one change for a specific segment of the team. For example, conduct a test of change around depression screening during the initial assessment. Historically in most practices, all depression screening has been conducted by the nursing staff. So, practices could test having the medical assistant initiate the PHQ-2 test for depression during the visit. You then refer patients with positive screens to nurses for a PHQ-9 test, who then refer patients to the physician for further assessment, as needed.
Think about the possibilities of having each member of the team working to the highest level of their training, experience, and licensure. Small-scale tests can help develop confidence and trust in the team-based approach.
Q: What are some ways team-based care impacts physicians who are part of those teams?
The majority of physicians who are experiencing good team-based care love it — there is less waste and it’s more efficient. Physicians typically appreciate and savor the idea of reduced waste in their day.
Team-based care gives providers more face-to-face contact with patients with fewer interruptions. Practice staff get out of work on time so they can attend soccer games and be at family dinners, processes become more reliable, and clinical outcomes improve.
Team members are working to the highest level of their licensure, so there is greater joy and satisfaction in work for the whole care team. Staff retention is a benefit, which gives the physicians and patients continuity with a well-functioning and reliable team. A highly functional team approach enables providers to spend more time doing what only they can do, what they love most, and what they went into medicine to accomplish.
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