Applied Evidence

Advanced team-based care: How we made it work

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I increasingly feel that I’m understood. We have seen patients develop meaningful relationships with other team members, confiding in them in ways that they hadn’t always done with physicians and advanced practice clinicians (APCs). Team members, in turn, have added valuable insights that help optimize patients’ care. In particular, the care of patients with multiple needs has been enhanced with the addition of ECT members who work with the core team and use their expertise to optimize the care of these patients.

Certified medical assistants and licensed practical nurses

Bellin’s leadership knew that team documentation could cause stress for the CMA, who, acting as a CTC, wanted to avoid misrepresenting details of the clinical encounter.13 Adding to the stress were other duties that would need to be learned, including agenda setting, refill management, care gap closure, and health coaching. With thorough training and preparation, many—but not all—of our CMAs and LPNs were able to successfully make the transition and flourish.

Implementation strategies

Provide thorough training. Our training process started 8 weeks before it was time to “go live.” There were weekly hour-long training sessions in population health basics, team culture and change management, documentation basics, and new roles and responsibilities. In the final week, the entire aTBC team sat together for 3 days of EHR training. All new teams shadowed existing teams to get a clear picture of the new processes.

Create a community of support. As our CMAs adapted to their new CTC roles, it was critical that they had support from experienced CTCs. Encouragement and patience from physicians were—and are—essential for CTCs to develop confidence in their new roles.

Enable ongoing feedback. We introduced weekly team meetings to enhance team communication and dynamics. Forums for all roles are held periodically to facilitate discussion, share learning, and enable support between teams.

Continue to: Use EHR tools to facilitate this work


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