Team-based care isn’t a new concept — providers have always collaborated to achieve the best outcomes for their patients. However, the lower costs and improved outcomes associated with outcome-based models are driving this teamwork to new levels of popularity.
Provider teamwork is becoming more formalized through shared care plans that team members develop together to address each patient’s unique goals, needs, preferences and challenges. The concept of this “team” is also expanding beyond health care providers to include community organizations and employers, among others.
Employers benefit from these care models as well, since employees will have access to high-quality care with the power to reduce absenteeism and save money on overall health care costs. On the employees’ end, this type of care is appealing because it provides:
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
More cost-effective care under an outcome-based model
When multiple entities collaborate to care for patients, patients can receive comprehensive care. The shared workload also helps ease some of the burden for doctors and prevent physician burnout.
Members of the Team and Their Contributions
Team-based care happens when at least two health providers join forces to work with payers, patients, their families and their larger communities to deliver more effective care. Payers should implement payment models that incentivize the collaboration between providers to help deliver differentiated member experience. When it’s implemented well, this style of care has the potential to offer patients an experience that’s less disjointed, higher value and more efficient.
Core members of the team may include a physician, specialist, nurse and health coach. The extended team may also have a behavioral health consultant, dietitian, social worker, clinical pharmacist and care coordinator. Affiliated members may range from community organizations staff to an employer. Each member of the team works to the highest level of their licensure, experience and training to meet the needs of the population.
This care model addresses social determinants of health as well, because it recognizes that many of the factors that influence health originate outside of the provider setting. A team-based approach fosters a collaborative approach to whole-person care within an outcome-based program.
The underlying themes in every model are communication and collaboration. Regardless of whether the team is completely internal or extends far beyond the four walls of the medical practice, communication and collaboration reduce workflow bottlenecks so the team can focus on providing safe, timely, effective, efficient, equitable and patient-centered care. Each member of the team contributes their expertise and shares insights that ultimately reduce unnecessary services and prevent duplication of services.
Consider a patient with an uncomplicated diabetes case. In a team-based model, a medical assistant may take the patient’s vital signs. A nurse may then perform the initial assessment and foot exam, a dietitian or diabetes educator may discuss dietary requirements and restrictions, and a clinical pharmacist may review prescriptions with the patient so that they understand the purpose of each medication. In the workplace, the patient’s employer may incorporate diabetes management into its employee wellness program and ensure that all employees have access to a separate refrigerator for insulin storage. The patient benefits from each team member’s expertise to have a coordinated experience to help improve outcomes. It’s a win-win scenario.
Complementing Value-Based Care
Team-based care complements value-based care because it’s designed to improve health outcomes. For example, at the Chinle Service Unit in Chinle, Arizona, community health representatives and public health nurses from the community collaborate with the clinic’s care team to offer home visits that serve as alternatives or supplements to one-on-one physician visits. Bellin Health in Green Bay, Wisconsin, used this care model to reduce its readmission rate and monthly costs by more than 10% for patients with congestive heart failure. Among other things, Bellin Health assembled an extended care team including case managers, diabetes educators and care coordinators; held regular team meetings; and improved communication with payers to lower costs and strengthen care. CareSouth Carolina, a community health center in Hartsville, South Carolina, co-located behavioral health providers in its primary care clinics to improve depression management.
Team-based care paves the way for an outcome-based model. Seeing this transition through will require support from a wide range of people and organizations — and employers play an important role in improving outcomes and reducing costs.