Turning team-based care into a winning proposition

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Applied Evidence

Turning team-based care into a winning proposition

J Fam Pract. 2015 March;64(3):159-164

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References

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12. Willard R, Bodenheimer T. The building blocks of high-performing primary care: Lessons from the field. April 2012. Available at: http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/B/PDF%20BuildingBlocksPrimaryCare.pdf. Accessed February 10, 2015.

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16. Bloom FJ, Graf TR, Steele GD. Improved patient outcomes in 3 years with a system of care for diabetes. October 2012. Available at: http://iom.edu/~/media/Files/Perspectives-Files/2012/Commentaries/VSRT-Improved-Patient-Outcomes.pdf. Accessed February 10, 2015.

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19. Scanlon DP, Hollenbeak CS, Beich J, et al. Financial and clinical impact of team-based treatment for medicaid enrollees with diabetes in a federally qualified health center. Diabetes Care. 2008;31:2160-2165.

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What are the barriers to creating team-based care?

Many providers and administrators are concerned about the costs of creating a team-based model of care. These include the cost of hiring new staff, retraining current staff, and educating team members and patients, as well as the cost of developing and maintaining the necessary information technology.

There is, of course, always the concern about physicians relinquishing patient care tasks to other team members. The flip side of that is that staff members may not be eager to increase their roles and responsibilities. In addition, developing a high-functioning team requires ongoing efforts to train and retrain, as well as dedicated leadership and an ongoing commitment to team building.¹²

Team-based care can work well for managing chronic diseases

Despite the challenges of developing and maintaining this approach to care, the evidence suggests that implementing a team-based model can be especially useful for patients with chronic diseases, because it can improve patient outcomes and access to care, decrease costs, and improve clinician satisfaction—as detailed below.

Studies have shown that using a team approach results in improved metrics, including HbA1c, cholesterol, BP, and BMI.Improved patient outcomes. Initial evidence suggests that implementing a team-based model can improve patients’ health and experience of care.^13,14 The most positive findings have been observed for team-based efforts at managing specific diseases, such as diabetes and congestive heart failure (CHF), or specific populations, such as older patients with chronic illness. Studies have shown that using a team approach results in improved metrics, including HbA1c, low-density lipoprotein cholesterol, blood pressure (BP), and body mass index.^7,15-20Team-based models that pair physicians and other primary care providers with a clinical pharmacist have increased patients’ medication adherence and provider adherence to recommended prescribing habits.^15,21-23

One small clinical microsystem that focused on self-management support with health coaching increased patients’ ratings of their confidence in self-management from 40% to 60% at baseline to 80% to 90% after one year. This program also increased the proportion of patients in whom BP was controlled by 10% to 15%.¹⁰

Despite these successes, some team-based models may not always be “doable” because of the costs of adding an advanced practice clinician to the staff, or the challenges of recruiting the right person for the job. (How to adapt team-based care for smaller practices is discussed below.)

Improved access to care. A preponderance of data shows that team-based care increases the volume of patient visits, thereby improving access to care.^7,21,24-28 The critical elements to successfully achieving this are effective training and delegation. In private practice, using well-trained clinical assistants to create a physician-driven team can increase patient visit volume by an estimated 30% (using 1 assistant) to 60% (using 2 assistants).²⁴

Similar increases in visit volume are seen in larger patient-centered medical home (PCMH) models that consist of physicians, PAs or NPs, MAs, LPNs, RNs, and clinical pharmacists.^7,25 Teams with defined ratios of assistants to physicians/NPs/PAs see the most patients per day compared to care coordinator models (ie, 1 assistant for multiple physicians) or enhanced traditional models.²¹ When focusing on disease-specific care, the impact on access can be even greater. A diabetes-specific team-based care program resulted in a >50% increase in daily patient encounters and 4-fold increase in annual office visits.²⁸

In addition to increasing visits, team-based care also increases access to care by decreasing wait times for an appointment and increasing the use of secure messaging and telephone visits.^7,25 In a prospective cohort pilot study of more than 2000 patients enrolled in a team-based care model, the average scheduling time for a face-to-face visit for nonurgent care decreased from a mean of 26.5 days to 14 days, compared to a mean of 31.5 days to 17.8 days for controls.²⁵ (The decrease in the control group was likely due to implementation of an electronic medical record in the practice.) Furthermore, a non-controlled evaluation of health plan-based practice groups with very large patient populations (ie, >300,000 patients) reported up to a 3-fold decrease in appointment waiting time when using a team-based model.²⁹

Some studies have found a decrease in office visits after implementing team-based care.⁷ However, these reports also found a corresponding increase (by as much as 80%) in the use of secure messaging and telephone encounters, which translated to an overall enhanced communication with patients and ultimately increased access to care.⁷

Decreased costs. Several controlled trials have looked at the financial impact of using team-based care to manage chronic conditions such as asthma, CHF, and diabetes. Rich et al³⁰ found a nurse-directed program of patient self-management support via telephone and home visit follow-up was associated with a 56% reduction in hospital readmissions, which translated to a $460 decrease in cost per patient over a 3-month period compared to a control group. In a study by Domurat,³¹ hospital stays were 50% shorter for high-risk diabetes patients who were managed by a team that offered planned visits, telephone contact, and group visits; this resulted in a lower cost of care. Katon et al³² found that when a nurse manager was added to a primary care team to enhance self-management support, intensify treatment, and coordinate continuity of care for patients with multiple chronic conditions, outpatient health costs were decreased by $594 per patient over 24 months.