Applied Evidence

Turning team-based care into a winning proposition

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Team-based care can go a long way toward improving patient outcomes. This review—with accompanying tips and resource lists—can help.




› Explore the potential benefits of team-based care by conducting a full assessment of your practice, including patient panels, payer mix, current finances, regional pay-for-performance programs, leadership support, and your staff’s training and talents. A
› Consider partnering with a local pharmacist or with insurers to use their community health workers, nurse case managers, and other self-management support tools. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

The Institute for Healthcare Improvement’s “Triple Aim” approach to optimizing the delivery of health care in the United States calls for improving the patient’s experience of care, including both quality and satisfaction; improving the health of populations; and reducing the per-capita cost of health care.1 Unfortunately, achieving these goals is being made more challenging by a perfect storm of conditions: The age of the population and the number of people accessing the systems are increasing, while the number of providers available to care for these patients is decreasing. The number of annual office visits to family physicians (FPs) in the United States is projected to increase from 462 million in 2008 to 565 million in 2025, which will require an estimated 51,880 additional FPs.2

One of the health care delivery models that has recently gained traction to help address this is team-based care. By practicing in a team-based care model, physicians and other clinicians can care for more patients, better manage those with high-risk and high-cost needs, and improve overall quality of care and satisfaction for all involved. Here we review the evidence for team-based care and its use for chronic disease management, and offer suggestions for its implementation.

The many providers who comprise the team

There is little consistency in the definition, composition, training, or maintenance of health care teams. Naylor et al3 defined team-based care as “the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care.”

While the team construct will vary based on the needs of your practice and your patients, developing a high-functioning team is essential to achieving success. Our 12-step checklist for building a successful team is a good starting point (TABLE 1).4-6 Many other resources are available to help with each step of this process (TABLE 2).

Teams should be led by a primary care provider—a physician, nurse practitioner (NP), or physician assistant (PA)—and consist of other members that complement the other’s expertise and roles, such as nurse case managers, clinical pharmacists, social workers, and behavioral health experts. Some practices have large teams with interdisciplinary members, including pharmacists, PAs, and NPs (the “expanded staffing” model), while others form smaller “teamlets” consisting of a physician and a registered nurse (RN) who serves as a health coach.

In the expanded staffing model, RNs and clinical pharmacists assume greater care management, while medical assistants (MAs) and licensed practice nurses (LPNs) are responsible for pre-visit, outreach, and follow-up activities.7 Redefining roles can spread the work among all team members, which allows each member to work to their level of training and licensure and permits the MD/NP/PA to focus on more complex tasks.

In the teamlet model, care is expanded beyond the usual 15-minute visit to include pre-visit, visit, post-visit, and between-visit care.The teamlet model has 2 main features: 1) Patient encounters involve a clinician (MD, NP, PA) and a health coach (MA, RN, LPN); and 2) Care is expanded beyond the usual 15-minute visit to include pre-visit, visit, post-visit, and between-visit care.8 Incorporating a health coach puts an increased focus on the patient and self-management support, with the goals of increasing satisfaction for both the patient and the health care team, improving outcomes, and lowering cost due to fewer emergency department (ED) visits and hospital admissions/readmissions.

Smaller teams seem to be more effective and more manageable.8,9 In one example of well-functioning teamlet composed of RNs and MAs, an MA is responsible for patients coming in for timely chronic and preventive care needs, while the RNs focus their efforts on tasks that require their expertise, including health coaching, self-management support, and patient education.9 Although smaller offices may not have the resources of a large academic practice, this model of maximizing the role of the MAs is reasonable and achievable.

Another example of a successful teamlet model is a clinical microsystem, in which a small group of clinicians and support staff work together to provide care to a discrete group of patients.10,11 (For more information on clinical microsystems, go to the Dartmouth Institute Microsystem Academy at


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