Turning team-based care into a winning proposition
Team-based care can go a long way toward improving patient outcomes. This review—with accompanying tips and resource lists—can help.
Liu et al33 randomly assigned 354 patients in a VA primary care clinic who met criteria for major depression or dysthymia to usual care or a collaborative care model. The collaborative care model included a mental health care team that provided telephone contact to encourage medication adherence and reviewed and suggested modifications to the treatment plan. After an initial expenditure of $519 per patient, a savings of approximately $33 per patient for total outpatient costs was realized.
A team-based coordinated care program for patients with multiple chronic conditions reduced patient visits to specialists by 24%, ED visits by 13%, and hospitalizations by 39%.34 An internal evaluation found that the program saved money by reducing admissions, including intensive care unit stays and “observational” stays for Medicare fee-for-service patients.35
What about reimbursement? Most studies that have evaluated the financial aspects of implementing team-based care have calculated the cost savings for the health system—rather than for an individual practice—through decreased hospital admissions, readmissions, and ED visits. Efficient, high-quality teams will require a substantial initial investment of time and hiring and training of staff before savings can be realized.
Team-based care may not be financially sustainable unless current reimbursement models are changed. The current US system bases payment on quantity of care instead of quality of care, reimburses only for clinician services, and does not compensate teams.36 The Centers for Medicare and Medicaid Services (CMS) has begun to recognize the need to reimburse for services that are not delivered in face-to-face patient encounters. For example, the agency established a new G-code that can be used for non-face-to-face care management services for Medicare patients with 2 or more significant chronic conditions; this code took effect on January 1, 2015.37
Some insurers are reimbursing practices for obtaining designation as a PCMH. This type of reimbursement could be expanded to include other types of team-based efforts—such as self-management support and health coaching.
Improved team satisfaction. While many primary care providers are experiencing fatigue and burnout,38 support staff in many practices also experience job dissatisfaction, which leads to increased absenteeism and high turnover. Several studies indicate that involving all levels of staff in the improvement process and empowering them to work to their full potential by enhancing their roles and realigning responsibilities can increase satisfaction.7,11,21,38,39 This in turn can lead to increased loyalty, commitment, and productivity, with decreased burnout and turnover.
TABLE 2
| Team-based care: Additional resources | |
| Resource | Comments |
The Dartmouth Institute Microsystem Academy | This site includes assessment tools and strategies for implementing clinical microsystems into practices |
Improving Chronic Illness Care | This site provides information about the chronic care model, care coordination, and patient-centered medical homes |
TeamSTEPPS | TeamSTEPPS is an evidence-based teamwork system to improve communication and teamwork skills among health care professionals. All resources, including training materials, are free and downloadable |
Godfrey MM, Melin CN, Muething SE, et al. Clinical microsystems, Part 3. Transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies. Jt Comm J Qual Patient Saf. 2008;34:591-603. | This article provides resources and strategies to engage all levels of the health system in team-based care |
McKinley KE, Berry SA, Laam LA, et al. Clinical microsystems, Part 4. Building innovative population-specific mesosystems. Jt Comm J Qual Patient Saf. 2008;34:655-663. | This article describes how to engage leadership at the health systems level |
Adapting team-based care for smaller practices
Physicians who practice alone or in small groups may have limited capacity to employ allied health professionals. However, your “team” doesn’t need to be housed only in your office. One innovative approach is the community-based medical home, where physicians with medical homes and/or care teams in their offices refer to, and collaborate with, a network of community-based professionals and agencies for clinical and social service support for their patients.22 Some options are to partner with a local pharmacist or with insurers to use their community health workers, nurse case managers, and other self-management support tools.
While having team-based care strategies is necessary to achieve a PCMH designation, you do not need to seek such designation in order to practice team-based care. Start 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. In addition, determine what you value for your practice and what outcomes you hope for, along with a clear plan of how to measure these outcomes. This will allow you to determine if the estimated cost of the proposed strategy is “worth it” in terms of your individual situation and goals.
