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Workflow and Process Module 0.5 Credit CME

Implementing Team-Based CareEngage the entire team in caring for patients

Team-Based Learning
Learning Objectives:
At the end of this activity, you will be able to:
1. Define elements that constitute the model of team-based care
2. Describe how to implement team-based care in your practice
3. Identify benefits of implementing team-based care in your practice

STEPS Forward™ is a practice improvement initiative from the AMA designed to empower teams like yours to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment. Wherever you find your team on the practice improvement continuum, the American Medical Association can help you take the next steps – the right steps – to improve your practice. Learn more

How will this module help me implement team-based care?

  1. Illustrate the impact of the practice model

  2. Provide step-by-step implementation guidance

  3. Offer resources and documents that can assist with implementation

Introduction

In STEPS Forward™, several modules describe individual elements of a team-based care model. In this module, we show how to bring all of these elements together.

What is team-based care?

Quiz Ref IDTeam-based care is a strategic redistribution of work among members of a practice team. In the model, all members of the physician-led team play an integral role in providing patient care. The physician (or in some circumstances a nurse practitioner or physician assistant) and a team of nurses and/or medical assistants (MAs) share responsibilities for better patient care. Common shared responsibilities include pre-visit planning and expanded intake activities, including reconciling medications, updating the patient’s history and collaborating with the patient to set the visit agenda. During the physician portion of the visit, the nurse, MA or documentation assistant scribes the visit, allowing the physician to have uninterrupted time with the patient. At the conclusion of the visit, the nurse or MA conducts essential care coordination activities, such as arranging follow-up visits or ordering requested testing and referrals.

Why team-based care?

Physician-led team-based care engages a greater number of staff in patient care and affords physicians the time they need to listen, think deeply and develop relationships with patients. Team members are aware of the patient’s health history and conditions and are thus better equipped to answer patients’ between-visit questions, calls and messages. As a result, all members of the physician-led team feel engaged in their key role of caring for the patient.

“We have MA care coordinators who are responsible for their own panel of patients. They work under protocol to refill meds, perform routine health maintenance and chronic disease monitoring tests and triage calls and e-mails from patients. They scribe visits, coach patients about action plans and facilitate referrals. It is working really well for all of us. The team is better than ever.”

Ann Lindsay, MD Stanford Coordinated Care

Ann Lindsay, MD Stanford Coordinated Care

STEPS to implementing team-based care

  1. Engage the change team

  2. Determine the team composition

  3. Choreograph workflows to reflect the new model of care

  4. Increase communication among the team, practice and patients

  5. Use a gradual approach to implement the model

  6. Optimize the care model

Step 1 Engage the change team

Bring together a multi-disciplinary change team of nurses, MAs, physicians, administrators and information technology staff members with a leader who has enough authority within the practice or organization to empower the process. Consider involving patients on the change team as well.

Quiz Ref IDIn addition to building the change team, assemble a smaller team that will pilot the team-based care model in your practice. This pilot team may consist of one physician or a pod of physicians. The physicians and team members who are involved in the pilot should also be members of the larger change team.

Step 2 Determine the team composition

Design the model of care that will meet the needs of your patients and team. Consider which current team members could learn a new skillset and fulfill a new role on the physician-led team. Your practice model may include a behavioral health specialist, health coach, care manager, care coordinator, nurse practitioner, physician assistant or reception staff. Depending on the physician’s specialty, athletic trainers or ophthalmic technicians may also be vital team members.

While designing the team composition, start to consider which team could pilot the model. Ensure that the pilot team(s) consists of physicians and supporting team members who are eager to transform the clinic to a team-based care model. They should be trailblazers, trendsetters and good communicators who are willing to put in extra effort to prepare for the transition and continue to develop the new model once it is underway.

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Q&A

  • Our biggest problem is access to care. Will team-based care help with this?

    Yes! When the team is working efficiently, there is greater capacity to see more patients. One physician who recently implemented team-based care was able to re-open his practice to new patients after it had been closed for more than twelve years. Another physician increased his daily patient access from 21 to 28 patients.

  • What should we do if our nurses don’t want to work as scribes?

    The nurse’s role in team-based care is not “scribing.” It can be better thought of as a “nurse co-visit” where the nurse manages preventive care and much of the chronic illness monitoring under established protocols and begins to explore any acute symptoms that the patient may have. The physician provides oversight and additional medical decision-making. This advanced team-care role offers nurses an opportunity to continuously learn and make more meaningful contributions than they would in a traditional triage or prescription refill position.1

    Some practices have trained MAs to scribe visits and manage prevention and illness monitoring by protocols or standing orders. A nurse may supervise a group of advanced MAs. Work with your practice to identify which existing team members could work in desired capacities to implement the new model, and plan to continue to develop roles and training as the new model is adopted. Individual roles and scope of practice should be defined in accordance with your state’s laws.

  • One of our pilot physicians has concerns about the adaptability of his team. Do you have any suggestions?

    Adopting a new practice model requires adaptability, openness and innovation. It is natural for providers and staff to feel uncomfortable with change. Some people are so busy working in a less functional model of care that it is hard to find time to imagine and plan for a better way. Strong support from a project champion high in the organization is critical. Ensuring that everyone who will be impacted by the change has an opportunity to shape the change increases the chance of success. Also, try to have a little fun along the way.

Estimate Savings From Team-Based Care

This calculator enables you to estimate the cost and benefit of implementing team-based care in your practice. Enter the amount of time per day spent by physicians on activities that could be eliminated by implementing team-based care and the estimated cost of the specialist. The result will be daily physician time saved and annual savings of implementing team-based care.

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Calculate your savings
Calculate your savings
Step 3 Choreograph workflows to reflect the new model of care

Determine your new team-based care workflows. Remember, you are creating your ideal future state, so think outside the box when designing your dream team and ideal practice. If you have access to a Lean expert, work collaboratively to identify opportunities for greater efficiency in the current and newly designed processes. If certain aspects of your current workflow function well, feel free to incorporate them into your future state! Try not to limit yourself; consider how an already great process can be made better.

Step A Effective pre-visit activities

Ensuring that your patients and team are prepared for patient visits is one of the cornerstones of team-based care. Pre-visit planning activities can be completed by a designated nurse, MA or other team member. Some offices focus pre-visit planning efforts on the more complex patients or chronic care patients. Using a registry can streamline this work by making it easy to see the gaps in care or missing elements of critical clinical information.

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Q&A

  • What can increased efficiency do for my practice?

    Increased efficiency can result in increased productivity. The physician-led team is able to see more patients during a single clinic session. The increase in patient revenue is usually more than the cost of any additional staff.

    Increased efficiency can also improve quality. When the care team is efficient, the correct routine care happens naturally. In addition, the physician can focus more of his/her efforts on listening deeply to the patient, making accurate diagnoses, creating treatment plans consistent with the patient’s preferences and communicating with other professionals involved in the patient’s care.

  • What activities should we complete when conducting pre-visit planning?

    Conduct pre-visit planning two to three days prior to the visit.

    • Review notes from the previous visit and ensure that follow-up results (e.g., laboratory test results, x-ray or pathology reports, other provider notes from a referral) are available for physician review

    • Use a registry or visit-prep checklist to identify any care gaps or upcoming preventive and chronic care needs

    • Identify whether any further information is required for the visit (e.g., hospital discharge notes, emergency department notes or operative notes from a recent surgery)

    • Remind patients of their appointments by sending automated (if possible) appointment reminders, including the accurate check-in time and accounting for the additional time it will take to complete any necessary paperwork, such as a pre-appointment questionnaire

  • What should we do to complete pre-visit laboratory testing?

    Order pre-visit labs at the end of each appointment to be completed prior to the next appointment using a visit planner checklist. Providers can review results with the patient in person. This saves time and allows the care team to discuss progress and/or interventions with the patient.

  • Is it important that we start the day or session with a team huddle?

    Prepare the team by reviewing the day’s schedule during a five to 15 minute team huddle. The huddle should include the extended care team, such as registration or check-in staff, the physician, nurses, MAs, behavioral health specialist, care manager and health educator, as appropriate. The team can discuss important items that are pertinent to all team members to sustain the greatest efficiency and cohesion throughout the clinic day and to make sure that resources are allocated where the anticipated need will be. For example, the team may discuss who is covering for a team member who is sick and for another who will be out in the afternoon. They can make sure that the procedure room will be set up for the 10:00 a.m. appointment where the patient will need an endometrial biopsy. The huddle should involve and engage all members of the team.

Pre-visit planning activities and huddles prepare the clinic team and shift the model from one that is reactive, in which the team feels as though they are playing catch-up, to one that is proactive, in which the team anticipates, coordinates and delivers the best patient care. It also involves the care team and engages them in their enhanced roles that are essential to the delivery of patient care.

Step B The team-based patient visit

Quiz Ref IDThe nurse or MA manages the first component of the visit, including updating the medical record, closing care gaps and obtaining an initial history. When the physician joins the appointment, the nurse, MA or documentation specialist helps document the visit. At the end of the visit, the team member emphasizes the plan of care with the patient and conducts motivational interviewing and education as appropriate. The nurses and/or MAs become more knowledgeable about the treatment plan, can more effectively coordinate care between visits and develop closer independent relationships with patients and their families.

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Q&A

  • What are some of the expanded rooming activities that the team could do?

    In expanded rooming, the nurse or MA is empowered to:

    • Reconcile medications

    • Update medical, family and social history

    • Provide immunizations

    • Screen for conditions based on practice protocols

    • Identify the reason for the visit and help the patient set the visit agenda

    • Arrange preventive services based on standing orders

    • Assemble medical equipment or supplies prior to the visit

    • Hand off the patient to the physician

  • How does team documentation work?

    In team documentation, either a clinical person (nurse or MA) or trained clerical person documents, or “scribes,” the visit. There are benefits to both approaches:

    • The MA or nurse is able to remain with the patient throughout the visit, conducting rooming activities before the visit, documenting the visit while the physician is in the room and reemphasizing and educating the patient at the end of the visit. He or she is able to provide real continuity for the patient, building trust between the patient and care team. Between visits, the same team member is also well prepared to answer any questions from the patient that may arise. This approach enhances the nurse’s or MA’s relationship with each patient.

    • The primary responsibility of the clerical documentation specialist is to shadow the physician and document all patient visits, enabling the physician to connect with his or her patients. In some practices, documentation specialists may have additional responsibilities, such as care coordination and scheduling follow-up appointments.

  • How can we use the annual visit to synchronize prescription renewals?

    At an annual visit, the physician can indicate which chronic medications may be refilled for the entire upcoming year (or the maximum duration allowed by state law), and which, if any, to modify or discontinue. This can reduce the number of calls and amount of work associated with more frequent renewal requests. Of course, the team can provide refills upon request based on protocols.

  • When should planning for the next visit start?

    Planning should occur at the conclusion of the current visit. A visit planner checklist or an equivalent electronic checklist can help by clarifying the upcoming appointments and the corresponding laboratory and diagnostic work that should be completed prior to those visits, including the next annual comprehensive care visit.

When the physician portion of the visit is complete, he or she can exit the room, review the notes, make any modifications and sign the note. The physician is then ready to transition to the next patient’s room.

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Q&A

The patient should leave the visit with a sense of commitment and support from the clinic staff.

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Q&A

  • How many people does it take to carry out all of these responsibilities?

    Every practice is different. In one practice, team-based care is most effective with two MAs per physician. Another utilizes three RNs per physician. Practices develop varied extended care-team compositions as well. Some practices delegate pre-visit planning activities to panel managers or other care coordinators.

  • Can licensed staff enter electronic orders, such as laboratory or x-ray requests?

    Yes, certain credentialed individuals may enter orders for diagnostic tests in an office (non-facility) setting. Medicare generally requires that services provided/ordered be authenticated by the author. A physician’s failure to properly authenticate an order could lead to denial of payment by a MAC. However, there are circumstances where Medicare does not require a physician signature, such as for diagnostic tests (e.g., clinical diagnostic laboratory tests and diagnostic x-rays), when ordered in an office setting. While these orders need not be signed by the physician, he or she must clearly document in the medical record his or her intent that the test be performed. Providers should also check state, local, and professional guidelines.

  • Under Medicare payment rules, can non-physician staff, such as a registered nurse (RN), licensed practical nurse (LPN) or medical assistant (MA), enter elements of an evaluation and management (E/M) visit without the physician present?

    Yes, certain elements, like the Review of Systems (ROS) and Past, Family, and/or Social History (PFSH), may be recorded in the EHR by non-physician staff. Medicare guidance specifically allows ancillary staff to enter information derived from the patient for the ROS and/or PFSH. However, the physician must provide a notation in the medical record supplementing or confirming the information recorded by others to document that the physician reviewed the information. For other elements of a visit, like the History of Present Illness (HPI) or Chief Complaint (CC), Medicare rules do not explicitly indicate who may enter documentation. However, several Medicare Administrative Contractors (MACs) currently interpret Center for Medicare & Medicaid Services (CMS) regulations to prohibit the physician (or non-physician practitioner (NPP), if billing for the service) from delegating these elements of the service. Practitioners should check with their respective MACs before allowing individuals other than the treating physician to document an HPI or CC. If the non-physician is entering information about an HPI or CC on behalf of the physician while the physician is present in the room with the patient, some MAC guidance suggests that this practice is allowable as long as the physician actually performed the E/M service billed, the scribe simply served to transcribe the service provided by the physician, and the scribe’s entry is authenticated by the physician. Other MACs, however, restrict this practice. Providers should consult with their MAC before using a scribe to complete entry of an HPI or CC.

  • Under Medicare payment rules, can an RN document a patient’s medication list in the EHR as part of medication reconciliation (MR) during E/M visit?

    Yes, where MR is part of the ROS or PFSH for the E/M service, under Medicare payment rules, the medication list may be recorded by any ancillary staff, and then signed by the physician. MR is included in the Advancing Care Information performance category in the Merit-Based Incentive Payment System (MIPS) as well as the Meaningful Use (MU) program.

Step 4 Increase communication among the team, practice and patients

Start by keeping the practice aware of the change team’s pilot work. Physicians and staff may feel out of the loop and disengage if they are not involved.

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Q&A

Communicate the change team’s work to your patients as well. You may want to draft a letter announcing this exciting transition so patients know what to expect, incorporate information about the change into a personalized pre-visit phone call or simply let patients know of the changes during the rooming process. Pamphlets in the waiting and exam rooms could also be used to remind patients of the changes before their visit begins.

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Q&A

  • What should we communicate to our patients about team-based care?

    When communicating to patients, share some of these important details:

    • Patients can expect that the entire team will take ownership for them. The practice will refer to them as “our patient.”

    • Patients will be asked to come into the office before their appointment to have their pre-visit labs drawn. Explain to patients that this will allow their physician the opportunity to discuss results and any changes to care during their visit.

    • Their physician will be more connected with them during their visits. The physician will no longer sit at the computer during the visit; they will sit next to the patient and have a discussion about their needs and care plan.

    • Patients can expect to be joined by another team member during visits. Let patients know that having another pair of ears in the room will ensure that all of their concerns are noted and as a result, their care will be more thorough.

    • Assure patients that if they have privacy concerns, other team members can leave the room when the physician enters.

    • Solicit patient feedback. Add a question to your current patient survey about the care received in the new model, or create a brief survey specifically for patients who received care from the pilot team so you can determine how the patients perceive the care they are receiving.

Step 5 Use a gradual approach to implement the model

Team-based care implementation will be a gradual process. It will take time, and every day will not be perfect. Be patient; know that several months may go by before the team feels like they are really gelling in their new system.

One physician who has implemented team-based care recommends that physicians who are considering implementation make sure that they are completely committed because it is not easy. He followed up with, “I cannot imagine practicing any other way.”

An MA who works in a team-based care model said that it took her about two months to feel like she was really getting the hang of documenting patient visits for her physician. She worked very closely with him as he taught her his preferences and showed her how he edited every single patient note. This type of time commitment is necessary to successfully implement team-based care. As the model expands, an experienced MA can mentor or assist with training a new MA.

Step 6 Optimize the team-based care model
Step A Co-location

Teams that sit in closer proximity communicate with greater frequency and ease. Questions can rapidly be answered, reducing the time that someone may have to wait before completing a task or responding to a patient. Everyone will be aware of the work that their teammates are doing, enabling easier task-sharing and division of work. Finally, after a busy clinic day, your inbox will not be filled with messages that could have quickly been triaged by another team member during the day.

Step B Inbox management

In a team-based care model, the number of inbox messages that are sent to the team should decrease for several reasons.

  • Lab results are discussed during the visit, so the number of messages sent back and forth to discuss results or set up a call is significantly reduced.

  • Patients receive additional education at the conclusion of their visit, resulting in fewer questions after the visit.

  • Care coordination is enhanced. Patients will leave with their follow-up appointments, corresponding labs and diagnostics scheduled, so they should have fewer requests after leaving the office.

  • Referrals to supportive services such as behavioral health or to a health educator can be made during the visit. Involving additional team members in a patient’s care provides them with a point of contact for follow-up questions regarding these specific services.

Of the questions that do come into the office, the physician’s team should be able to handle most of them. The physician may delegate most questions and concerns to the nurses or MAs who work with him or her. Their knowledge of each patient’s case will be much greater in a team-based care model, and they will be able to answer most questions according to what was said during the visit or the plan of care that was determined. They will also build their skillset over time, further engaging them in this critical work.

“The benefits from team-based care have gone beyond what I envisioned. Originally, I simply hoped to regain eye contact with patients, as this is such an important assessment tool for me during visits. What I’ve seen has really gone way beyond that. Yes, my face time with patients is increased, but the visit is also more efficient and relevant. Since my documentation is now in “real time,” my notes are better and timelier. Our clinical staff is learning so much more now that they feel like they are truly part of a team and they enjoy the added dimensions to their clinical practice. They have more confidence when teaching patients during office visits as well as when they’re on telephone triage. Team care has been a win-win here. And best of all, families love it!”

David Lautz, MD, Stanford Coordinated Care
AMA Pearls
Learn more about team-based care

Visit our STEPS Forward™ modules that explore all of the topics covered in this module in even greater detail:

Consider role flexibility

Create a culture that is patient-centric rather than task-oriented. The practice culture is one where everyone works together to care for patients; you would never hear someone say, “That’s not my job,” when a patient needed them. The MAs on the doctor’s team may share responsibilities between rooming and answering calls and inbox messages, flexing to cover where patients need them most throughout the day.

Create time for new responsibilities

Work with the physicians and staff to remove less critical activities and waste. Expecting valued workers to add even more to a full plate could lead to dissatisfaction or burnout. See the STEPS Forward™ Lean module for more information.

Box Section Ref ID
Conclusion

Quiz Ref IDIn the team-based care model, patient-care responsibilities are shared among members of a team, which enables physicians and staff to better connect with their patients. Quality, efficiency and productivity should increase, and taking care of patients should become fun again. The whole team is able to provide care to patients, changing the practice culture from one that refers to “my patient” to one that shares “our patient” in this powerful practice model.

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Where CME credit is designated, the activity is part of the American Medical Association's accredited CME program. The AMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Article Information

Target Audience: This activity is designed to meet the educational needs of practicing physicians.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Planning Committee:

  • Alejandro Aparicio, MD, Director, Medical Education Programs, AMA

  • Rita LePard, CME Program Committee, AMA

  • Anita Miriyala, Graduate Intern, Professional Satisfaction and Practice Sustainability, AMA

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA

  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

  • Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

Author Affiliations:

  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA; Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

Faculty:

  • Ann Lindsay, MD, Co-Director Stanford Coordinated Care; Jeff Panzer, MD, Medical Director, Iora Health; Sara J. Pastoor, MD, MHA, Family Physician; Bruce Bagley, MD, Senior Advisor, Professional Satisfaction and Practice Sustainability, AMA; Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA; Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA; Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure statement: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

References
1.
Bodenheimer  T, Bauer  L, Olayiwola  JN, Syer  S. RN Role Reimagined: How Empowering Registered Nurses Can Improve Primary Care. http://www.chcf.org/publications/2015/08/rn-role-reimagined. Accessed August 12, 2015.
2.
Centers for Medicare & Medicaid Services.  Stage 2 Eligible Professional Meaningful Use Core Measures: Measure 1 of 17. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_1_CPOE_MedicationOrders.pdf. Published October 2012. Accessed September 14, 2015.
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