Finding team-based care elusive?

Thursday, September 27, 2018 | Ginger Biesbrock

 

I spoke at a conference recently and received this comment: “We have lots of folks on our team, but find that our team-based care delivery model is elusive.” I thought a lot about that comment as it describes many of our programs. We have a team of APPs, RNs and others working with physicians and yet, we don’t really have a team-based model. What is missing?

Let’s first start with the definition of a team-based model. A paper released just last week used the National Academy of Medicine’s definition: “Team-based healthcare is the promotion of health services to individuals, families and/or their communities by at least two health professionals 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.” What does this really mean? To me, it means that a group of healthcare professionals – physician, APP, RN, MA, scheduler – come together for a common cause, working together to manage a group of patients. This may be a patient panel, a group of structural heart patients, a group of HF patients, etc.

In my work with programs I am seeing a trend. For the areas within the program that are small, such as an outreach clinic or a small disease management clinic, I typically see a satisfied team with low turnover that enjoys the work they do. Compare that to the larger clinics where I see high turnover and, many times, frustration. Why is that? Because the larger environments have usually not organized themselves into small enough teams where folks are tied to the common cause or even know one another’s names. That environment spills over to our patients and their experience and quality of the care. Now, I am not advocating for such a small group that there is no flexibility. The one-to-one-to-one-to-one ratio is not sustainable. However, a smaller functional group with several physicians and two to three APPs, RNS, MAs, and a scheduler works well. The goal is to create the continuity of the team while maintaining flexibility and efficiency.

I am a huge fan of Professor Michael Porter and his work on healthcare delivery. His view focuses on value-based care delivery – cost and quality. “To deliver more value, providers need to focus on quality – on deepening their expertise, expanding their ability to serve the complex and interrelated needs of each patient over the full course of care. The greatest improvements in health care outcomes and efficiency will come from a sustained, team-based focus on a carefully defined set of medically integrated services and practices.” (https://www.isc.hbs.edu/health-care/vbhcd/Pages/integrated-practice-units.aspx) The greatest improvements in healthcare outcomes and efficiency will come from sustained, team-based focus. It’s not the right EMR, nor the right new device or technology. It’s the right team. While for many of you, it still seems elusive, I do want to report that we are getting there and it’s working.

There is evidence that multidisciplinary team-based care is associated with better performance on traditional measures of healthcare delivery such as ED and hospital utilization. Team work plays an important role in preventing adverse outcomes and there’s a proven relationship between staff perception of team work and attitudes about the importance of quality and patient safety. For example, a review of 52 studies of team-based care found that hypertension goals were achieved in 12% more patients than in traditional models. Patient self-management improved, glycemic control for diabetic patients improved, and in other studies survival outcomes improved (https://nam.edu/implementing-optimal-team-based-care-to-reduce-clinician-burnout/). In addition, there is evolving evidence that team-based care models reduce clinician burnout. Which brings me back to my one of original points – the small teams I have encountered (compared to the large teams) have a much better experience for the team members.  

Recommendations to avoid the ‘elusive’ care team.

1. Common Goals and Data — All members must understand the objective(s) of care that need to be met. They need data and outcomes that evaluate their performance showing areas of opportunity and areas of celebration. This includes both clinical outcomes and operational outcomes – and don’t be afraid to add financial outcomes.
2. “Everyone needs to know my name.”— This is true for patients and for the team. We need to develop relationships that have meaning. Physician leader and co-worker; ask me about my kids, my interests, my goals, etc. This is where mutual trust and respect are built. I am a huge fan of ‘cake day’ for example. Celebrate birthdays, special occasions and the team wins. It doesn’t have to be cake – but I sure do love cake!
3. Communication (Formal and Informal) — The team can’t be afraid to approach one another or to ask questions. If there is fear, the team will not function well. And clear communication also means that we are all rowing in the same direction. Time provided for huddles and team communication is invaluable.
4. Balance of Efficiency in Team Size – I will tell you that the smaller the team, the harder it is to keep the continuity and consistency. You can’t lose an entire set of skills when someone leaves or someone is on vacation. And yet, if we are too big and too interchangeable, we lose the relationship. Sometimes it can mean less flexibility around PTO, or last-minute coverage changes. However, the payoff will be worth it. So find a good practice scheduler and be willing to have conversations around what works best for the team as it relates to flexibility versus continuity.

Going back to the comment I started this blog post with, I want to acknowledge how much I appreciate it. That elusive concept is real. It’s easy for me to provide sample schedules, sample care plans, operational roadmaps—but it really does come down to goals, relationships and communication. As administrators, you need to set your teams up for success. As physicians, you need to lead your teams in a way that will empower them, celebrate them and allow them to be cohesive—to provide the best patient care possible and achieve the outcomes that you all desire. I promise you that if you have the right folks on the team, they care just as much about those patients as you do.

 

 

Illustration: Lee Sauer                   

 

 

 

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