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Team-Based CareImprove Patient Care and Team Engagement Through Collaboration and Streamlined Processes

Learning Objectives
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
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Learning Objectives

  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

Introduction

Quiz Ref IDTeam-based care is a collaborative system in which team members share responsibilities to achieve high-quality and efficient patient care. Team members include:

  • Physicians

  • Nurse Practitioners

  • Physician Assistants

  • Nurses

  • Medical assistants

  • Front desk staff

  • Other practice-specific team members such as pharmacists, behavioral health specialists, social workers, physical therapists, or care coordinators

Quiz Ref IDUnder the leadership of the physician, team members coordinate responsibilities such as pre-visit planning, expanded rooming and discharge activities, and team documentation. With the help of other team members, physicians are better able to connect with patients and remain focused on their primary task of patient care. This involvement helps improve team collaboration and pride in their work, workflow efficiency, and patient satisfaction.1

Five STEPS to Implementing Team-Based Care

  1. Create a Change Team

  2. Design Team-Based Care Workflows to Fit Your Goals

  3. Select a Pilot Team

  4. Implement Team-Based Care Workflows

  5. Track Outcomes and Optimize Your Processes

STEP 1 Create a Change Team

To get started, bring together a multi-disciplinary change team of nurses, medical assistants, physicians, administrators, and information technology team members with a physician leader who has enough authority within the practice or organization to empower the process. Consider involving patients or members of your Patient and Family Advisory Council on the change team as well.

The change team's task will be to design the team-based care model that will best serve your patients and team members. Consider expanding the roles of current care team members and add any new roles to create the ideal team model for your practice. For example, your practice model may call for a behavioral health specialist, health coach, care manager, care coordinator, nurse practitioner, physician assistant, and/or reception team members. Depending on the physician's specialty, physical therapists or ophthalmic technicians may also be vital team members.

“We have medical assistant 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 emails 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

It is important to communicate to the change team why team-based care is essential to a thriving practice.

Benefits include:

  • Increased access to care

    When the team is working efficiently, there is greater capacity to see more patients.

  • Increased efficiency, improved quality of care, and greater productivity

    Increased efficiency can improve quality. When the care team is efficient, the correct routine care happens naturally. In addition, the physician can focus more of their 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.

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

  • Tangible cost savings

    In the calculator below, 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.

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.

STEP 2 Design Team-Based Care Workflows to Fit Your Goals

Think outside the box when designing your dream team and ideal practice. Remember, this is your chance to create your ideal future. If you have access to a Lean expert or operations consultant, work collaboratively to identify opportunities for greater efficiency in the current and newly designed processes. If certain aspects of your current workflow function well, incorporate them into your future state. But try not to limit yourself; consider how an already great process can be made better.

The fundamentals of team-based care include:

  1. Pre-visit planning (including pre-visit laboratory testing and daily team huddles)

  2. Expanded rooming and discharge

  3. Team documentation

  4. Medication management (including annual prescription refills)

  5. EHR in-basket management (including patient portal management)

These processes are briefly described here, but explained in more practical detail in the separate linked toolkits.

Pre-Visit Planning

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, medical assistant, or another team member. Using a patient registry can streamline this work by making it easy to see the gaps in care or missing elements of critical clinical information.

Conduct pre-visit planning 1 to 3 clinic days prior to the visit. Suggested processes for your pre-visit planning include:

  • Reviewing notes from the previous visit and ensuring that results (eg, pre-visit laboratory test results, x-ray or pathology reports, other physician notes from a referral) are available for physician review

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

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

  • Holding daily morning team huddles to go over the schedule and anticipate any essential actions to prepare accordingly for patients with complex care needs on the day's schedule

Pre-visit planning for the patient's next visit should occur at the conclusion of the current visit. This includes ordering pre-visit labs for the next appointment at the end of the current appointment.

Pre-visit planning, pre-visit labs, and daily team 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.

Expanded Rooming and Discharge

Expanded rooming and discharge protocols involve a nurse or medical assistant initiating and closing out each patient visit. A rooming checklist is a useful tool to keep track of components of pre-visit planning and expanded rooming and discharge processes.

In expanded rooming, the nurse or medical assistant can:

  • Assemble medical equipment or supplies prior to the visit.

  • Identify the reason for the visit and help the patient set the visit agenda. A pre-visit questionnaire is useful for this purpose.

  • Enter certain elements, such as chief complaint, history of present illness, past family or social history, and the review of systems for new and established office/outpatient evaluation and management (E/M) visits. This information does not need to be redocumented by the billing practitioner; however, he or she must review the information, update or supplement it as necessary, and indicate in the medical record that he or she has done so.2

  • Reconcile medications.

  • Screen for conditions (eg, depression, falls) based on practice protocols.

  • Arrange preventive services based on practice protocols or care gaps identified during pre-visit planning.

  • Provide immunizations based on practice protocols and state laws.

  • Hand off the patient to the physician, quickly briefing the physician with the patient's visit objective, goals, and any other pertinent information. This is often called a mini-huddle.

In expanded discharge after the physician portion of the visit is complete, the nurse or medical assistant can:

  • Review orders and instructions with the patient.

  • Conduct motivational interviewing to help patients understand what behavior changes are necessary to see desired results.

  • Print and review an updated medication list and visit summary.

  • Answer any questions about the visit or plan of care.

  • Coordinate follow-up care by scheduling visits and appropriate laboratory tests.

Team Documentation

In team documentation, a clinical team member (nurse or medical assistant) or trained documentation specialist remains with the physician during the patient visit in order to document or “scribe” the visit. There are benefits to both approaches:

  • The medical assistant 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 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 medical assistant's relationship with each patient.

  • The primary responsibility of the scribe/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.

Medication Management

Managing the care of patients who take multiple medications is another key component of team-based care. It is impractical for physicians alone to refill medications, reconcile medications, and ensure that patients are taking medications as prescribed.

One simple but powerful workflow is adopting synchronized annual prescription renewals. This process involves writing prescriptions for medications that treat chronic conditions so that all patients receive a 90-day supply filled 4 times a year.3 The shorthand for this is “90 x 4”. Choose one visit, such as the annual wellness visit, to renew all medications, even if there are still a few refills left on some of the older prescriptions.

This may seem intuitive, but you'd be surprised to find that many practices don't have standard processes for synchronizing and standardizing recurring patient prescriptions and lab orders. Eliminating frequent prescription renewals is the first step to improving how you and your team manage medications for your patients.

EHR In-Basket Management

Another core component of team-based care is managing the physician's EHR “in-basket.” The in-basket is the default destination for most forms of communication within the office. As the physician's patient panel grows, so does the volume of the in-basket, creating a burden that can be difficult to manage effectively during the day.

In a team-based care model, the number of in-basket messages sent to physicians should decrease for several reasons:

  1. 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.

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

  3. 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.

  4. Referrals to supportive services such as behavioral health or 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, particularly messages from patients, the physician's team should be able to handle most of them. An established workflow for patient portal messages is essential. In a team-based care model, nurses and medical assistants have much greater knowledge about each patient within the practice and should 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.

Box Section Ref ID

Q&A

  • What does a team-based patient visit look like from beginning to end?

    A patient checks in and is given a pre-visit questionnaire to fill out. The patient is then roomed by a nurse or medical assistant. The nurse or medical assistant reviews the pre-visit questionnaire, updates the medical record, reconciles medications, flags any potential care gaps, and begins obtaining an initial history.

    When the physician joins the appointment, the nurse, medical assistant, or documentation specialist is in the room to help document the visit. The physician notes to the team member during the visit what future orders/labs are necessary prior to the next visit, and the team member can place these orders in real-time. After the visit, the physician reviews the notes, makes any modifications, and signs the note. The physician is then ready to transition to the next patient's room while the other team members remain with the current patient.

    A team member stays with the patient after the physician leaves to review the plan of care and conduct motivational interviewing and education as appropriate. They may use the “teach-back” method to ensure patient understanding. Through this process, the team member becomes more knowledgeable about the treatment plan, can more effectively coordinate care between visits, and develop closer independent relationships with patients and their families. The patient also feels more taken care of and is more motivated to follow through with care team recommendations.

  • Is co-location important?

    Teams that sit in closer proximity communicate with greater frequency and ease. Questions can be answered rapidly, 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. After a busy clinic day, the in-basket will not be filled with messages that could have quickly been addressed in person by another team member during the day.

  • What should we do if our nurses or medical assistants don't want to work as scribes?

    The team member's role in team-based care is not “scribing.” It should be described as a nurse or medical assistant co-visit in which the team member manages preventive care and much of the chronic illness monitoring and education under established protocols. The co-visit is also an opportunity for the nurse or medical assistant to begin exploring any acute symptoms that the patient may have. The physician provides oversight and additional medical decision-making. This advanced team-based care role offers nurses and medical assistants an opportunity to continuously learn and make more meaningful contributions than they would in a traditional triage or prescription refill position.4,5

STEP 3 Select a Pilot Team

After the change team has agreed upon the basic team-based workflows, assemble a smaller team that will pilot the model. This pilot team may consist of 1 physician or a pod of physicians and their care team. Members of the pilot team should be trailblazers and good communicators willing to put in extra effort to prepare for the transition and continue developing the new model once it is underway.

It is important to set your pilot team up for success. When aligning the pilot team to the ideal team model developed by the change team, keep the following in mind:

Recognize That Role Flexibility Is Part of Practice CultureMake Time for Team Members to Learn New ResponsibilitiesEliminate Unnecessary Activities and Waste
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 medical assistants on the physician's team may share responsibilities between rooming and answering calls and inbox messages, flexing to cover where patients need them most throughout the day.Some practices have trained medical assistants by protocols or standing orders to document visits and manage prevention and illness monitoring. A nurse may supervise a group of advanced medical assistants. 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 will be defined in accordance with your state's laws.Work with the physicians and team to remove less critical activities and waste. By reducing time spent on non-valuable work, that time can be redirected to support team members learning new skills. Expecting valued workers to add even more to a full plate could lead to dissatisfaction or burnout. One way to tackle waste is with Lean methodology. Listen to your team, and empower them to speak up to initiate change.
Box Section Ref ID

Q&A

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

    Adopting a new practice model requires flexibility and an open mind. It is natural for clinicians and team members 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. The opportunity to participate in positive change that improves patient care should be perceived as exciting and fun, not burdensome.

STEP 4 Implement Team-Based Care Workflows

Now that you've designed your team-based care workflows and identified a pilot team, it's time to implement team-based care.

Prepare Your Pilot Team

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

A medical assistant who works in a team-based care model said that it took her about 2 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 patient note. This type of time commitment is necessary to successfully implement team-based care. As the model expands, an experienced medical assistant can mentor or assist with training a new medical assistant.

Inform Your Patients

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

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

  • Patients can expect that the entire team will take ownership of their care. 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 pre-visit will allow their physician 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 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.

  • Patient feedback is valuable. 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.

Keep the Rest of the Practice in the Loop

Keep the entire practice informed of the change team's pilot work. Uninvolved physicians and team members may feel out of the loop and therefore disengaged.

There are many opportunities and methods to communicate the progress with the practice. Consider:

  • Including the change team's work as a standing agenda item at team meetings and department gatherings

  • Broadcasting updates in a weekly email and/or an intranet discussion board

  • Co-locating physicians with the rest of their team in a common workspace to organically support communication and team culture

  • Conducting regular huddles and team meetings

STEP 5 Track Outcomes and Optimize Your Processes

As with any improvement process, your model will need to continue to evolve and grow along with the needs of your patients and the practice of medicine. Evaluate your processes, celebrate your successes, and then build upon them. Find tools and tips for piloting, assessing, improving, and leading change in our organizational culture toolkits. Remember: Try not to limit yourself; consider how an already great process can be made better.

Conclusion

In the team-based care model, patient-care responsibilities are shared among members of a team, which enables physicians and care team members 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.

“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 team 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

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Article Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

Disclaimer: AMA STEPS Forward™ content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward™ content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward™ content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward™ content.

About the AMA Professional Satisfaction and 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.

References
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Centers for Medicare and Medicaid Services.  Evaluation and management (E/M) visit frequently asked questions (FAQs) physician fee schedule (PFS).  November 26 , 2018. Accessed August 10, 2021. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-M-Visit-FAQs-PFS.pdf
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Sinksy  TA, Sinsky  CA.  A streamlined approach to prescription management.  Fam Pract Manag. 2012;19(6):11–15. https://www.aafp.org/fpm/2012/1100/p11.htmlGoogle Scholar
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Bodenheimer  T, Bauer  L, Olayiwola  JN, Syer  S. RN role reimagined: how empowering registered nurses can improve primary care. California Health Care Foundation. August 11 , 2015. Accessed July 22, 2021. http://www.chcf.org/publications/2015/08/rn-role-reimagined
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Jerzak  J.  Using empowered CMAs and nursing staff to improve team-based care.  Fam Pract Manag. 2019;26(1):17–22. https://www.aafp.org/fpm/2019/0100/p17.htmlGoogle Scholar

Disclaimer: AMA STEPS Forward™ content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward™ content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward™ content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward™ content.

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