IHI’s Cindy Hupke, BSN, MBA, is director for IHI's Transforming the Primary Care Practice seminar. In this blog post, she answers some common questions about team-based care and describes its advantages for patients and providers.
What is team-based care?
The definition of “team-based care” for all care settings that is most widely accepted and consistent with the World Health Organization principles of primary health care and inclusive of the six IOM aims for improvement is as follows:
The provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, efficient, and equitable. [Source: Naylor MD, Coburn KD, Kurtzman ET, et al. Team-Based Primary Care for Chronically Ill Adults: State of the Science. Advancing Team-Based Care. Philadelphia, PA: American Board of Internal Medicine Foundation; 2010.]
It’s also important to note that although we perhaps think of team-based care as being primarily an ambulatory care model, it is being used just as vigorously for acute, subacute, and chronic conditions in the hospital setting.
Is team-based care a new approach?
No, it has been in practice for a while and team-based care is currently the “norm” at some level in most organizations. For at least 15 years, IHI has been incorporating the team-based care approach as a high-leverage change in our work related to primary care. It started with the Chronic Care Model in the late 1990s. The approach builds on IHI’s Transforming Care at the Bedside (TCAB) work, with a major emphasis on “vitality and teamwork” and specific reference to “effective care teams.”
Team-based care is front and center within IHI’s current and past work with the Harvard Medical School, the Indian Health Service, Contra Costa, the federal Health Resources and Services Administration (HRSA), and the Transforming the Primary Care Practice program. It is an integral part of not only patient-centered medical home recognition, but also imperative to attaining advanced access (to help work down a backlog of appointments), and of primary importance when working on flow, improving chronic care management, and addressing preventive screening and follow-up. IHI has seen optimized care teams have a positive impact on a range of measures, including office visit cycle time, access to care, preventive screening, self-management goal setting and action planning, and medication reconciliation.
For hundreds of organizations across the country, IHI has offered solid change concepts and ideas on the selection and development of a care team, multiple well-tested methods to optimize the care team, and more recently, how that care team might extend beyond the traditional four walls of the clinic through community health workers, public health nurses, in schools, and elsewhere.
What are the advantages of the team-based approach for providers as well as for patients?
The attributes of quality in which physicians are most interested — as clearly outlined in the IHI white paper, Engaging Physicians in a Shared Quality Agenda — include patient outcomes and personal muda (waste), particularly wasted time. The use of a well-organized and optimized care team addresses both of those issues.
In my experience, the people who benefit the most — the patients and physicians — are often the biggest proponents for this approach once they understand and experience it. I know of physicians who were skeptical at first and then became strong proponents of the approach once they saw the impact on both patient outcomes and efficiencies.
Physicians understandably want to ensure that their high standards are being met. Until they trust that their care team members have the same focus and high standards they do, there will likely be pushback on the team-based model. It takes time and positive experiences to develop that trust. It also takes practice; success doesn’t happen overnight. An effective clinical care team learns from regular practice to fine tune their skills, has shared goals, struggles with learning new approaches, has clear roles and responsibilities, and learns to rely on and trust their team members. The best teams also communicate effectively.
While not all teams are at the same level of competence and effectiveness — assuming that the care team is well developed and optimized — there are many potential advantages for patients. They include enhanced access to care and services with a consistent care team; improved quality, safety, and reliability of care; enhanced health and functioning in those who have a chronic condition; and more cost-effective care. Patient and family experience also tends to improve with a high-functioning primary care team.
What does it mean to “optimize the care team”?
Optimizing the care team is critical to maximizing the supply of the clinic and improving the daily flow of work. Organizations are encouraged to assess the current needs of their patient population and identify the ideal composition for the care team. The specific mix of staff (number of physicians, nurses, assistants, technicians, clerks, etc.) will vary from clinic to clinic, but — in all cases — the clinic has to understand the types of services it provides, then decide how the work should be divided among the care team to “supply” those services. This approach begins with understanding the demand and adjusts supply to meet the demand (within the limits of clinic resources). This is different from an approach that develops an arbitrary care team mix and then tries to fit the demand into the supply.
After identifying the composition of the care team, we encourage organizations to ensure that all staff members are working to the highest level of their expertise and ability. Work should be matched to each staff member's licensure, experience and abilities, including physicians, mid-level providers, nurses, and other staff members.
Let’s consider the example of a diabetic patient. Does a physician need to do their foot exam? No, a nurse can do the initial assessment. Does a physician need to be the one to discuss their dietary requirements and restrictions? No, in fact, a dietitian — given the specialization of their training — might be a more effective educator. By reassigning these responsibilities to other care team members, the physician can then spend more time focusing on what matters most to patients, such as communicating with patients, collaboratively setting goals, or using their expertise for more serious conditions.
Optimizing care teams is not only about giving time back to physicians. This is also an issue for nurses. If we free nurses from tasks traditionally assigned to them but for which their skills are not necessary, they can have more time to do the work they find more challenging and satisfying as professionals and that is ultimately more important to patients.
To illustrate the idea of optimizing the care team, we often run an exercise with our primary care teams using cups [see photo above] to represent the typical ambulatory care team. The jelly beans in the cups represent each person’s current responsibilities. The cups are meant to be a snapshot of one team’s assessment of their structure, roles, and tasks. The potential overuse of the physician is represented by the cup on the far left, filled with jelly beans. We use the exercise to help teams reevaluate the care team’s roles and responsibilities. Seeing the physician’s cup overflowing inspires teams to consider all the tasks traditionally assigned to physicians and ask, “Who could do these tasks just as effectively?” and “How can we optimize the license, training, and experience of each member of the team to provide the best experience for the patient and family?”
Other methods to optimize the care team include using standard protocols, cross-training staff, using huddles to improve communication, and limiting interruptions.
Can the team-based approach help organizations pursue the Triple Aim of improving health, enhancing the care experience, and reducing costs?
Absolutely! An optimized care team will provide the expertise and resources (tools and time) to jointly plan and customize care and provide support for individuals and families to better manage their own health. By redesigning primary care services and structures to work effectively and efficiently on prevention, health promotion, and chronic disease management, you can improve outcomes and the care experience in a cost-effective way.
What would you say to skeptical patients who might view team-based care as a way to cut costs or who worry that it will mean spending less time with their primary care physicians?
It requires a shift in thinking for some people to understand the value and benefit of the team approach. We have been very provider-centric in hospitals and clinics across the United States and this has propagated the assumption in the patient’s mind that their care must come almost exclusively from the physician. However, by limiting the time physicians spend on activities that other care team members can effectively manage either prior to or following their office visit, effective and efficient team-based care can enhance the time patients spend with their provider.
Having said that, it is important to acknowledge that patients might be concerned that someone with less training and expertise than their physician might assume responsibility for their care and worry that this is driven primarily by a desire to cut costs. We need to get better at explaining to patients that we are instead utilizing different medical professionals to the full extent of their training and experience, and assure patients that when they need to see a physician they will. Providing care is indeed a team approach and the physician will be involved in decision making along with the other members of the team.
How does team-based care help address the challenges facing primary care physicians today?
Team-based care can help primary care physicians address a variety of their biggest challenges. As noted earlier, it helps physicians use their time more effectively, for example. Team-based care is also the only way to address the needs of an expanding patient population in the US with a simultaneous shortage of primary care physicians.
It’s also well-documented that there is a growing need to better address the needs of patients with chronic illnesses such as diabetes or congestive heart failure. The advantages to team-based care can extend into the community, especially when combined with some form of case management or care coordination, home visits, or other strategies. Care providers from a variety of disciplines on the team can help people better manage their conditions at home and in their community and avoid long and costly ED visits. An example of great community involvement is the model utilized by Chinle Service Unit in Chinle, AZ. Community health representatives and public health nurses from the community work collaboratively with the care team from within the clinic, making home visits and aligning their strengths and services in the best interest of the persons they serve. Optimizing the care team might also mean creating alternatives or supplements to one-on-one physician visits, such as group visits.
Why is primary care in need of not just change, but transformation?
The current infrastructure for primary care in the US is not sufficient to meet the population management needs of a primary care patient panel. Researchers have estimated that it would take 7.4 hours per working day to provide all recommended preventive care to a panel of 2,500 primary care patients (similar to the average US primary care panel of 2,300), plus 10.6 hours to adequately manage this panel’s chronic conditions. If you include the estimate that it takes 4.6 hours per day for acute care, this adds up to 22.6 hours per day. It’s also been estimated that an average of only 54.9% of adults in the United States received recommended care in each of those areas. It is not possible to achieve improved population health without substantial (versus incremental) change.
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Team-Based Care: Moving from Ideas to Action
WIHI: New Staffing Models for Primary Care
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