Team-Based Care | Clinical Pharmacy and Pharmacology | AMA STEPS Forward | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

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
0.5 Credit CME
How will this module help me?

  1. Illustrates the impact of this practice model.

  2. Provides step-by-step implementation guidance.

  3. Offers resources and documents that can assist with implementation.

Introduction

Quiz Ref IDTeam-based care is a collaborative system in which team members share responsibilities to achieve high quality patient care. In this model, physicians, nurses, nurse practitioners, physician assistants, and/or medical assistants coordinate responsibilities, such as pre-visit planning, expanded intake activities, medication reconciliation, updating patient information, and scribing, to provide better patient care. The interactions among team members and patients allow physicians to better connect and understand patient concerns. This helps to improve team collaboration and pride in their work, workflow efficiency, and patient satisfaction.1

5 STEPS to Implementing Team-Based Care

  1. Create a Change Team.

  2. Select a Pilot Team.

  3. Develop Team-Based Care Workflows.

  4. Implement Team-Based Care.

  5. Track Outcomes and Optimize Your Processes.

Step 1 Create a Change Team.

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.

Convene the change team to design the team model that will meet the needs of your patients and team-based care workflows. Consider expanding or growing the roles of current care team members and any new roles you may want to include in your ideal team model for team-based care in your practice. Your practice model may call for a behavioral health specialist, health coach, care manager, care coordinator, nurse practitioner, physician assistant, or reception team members. Depending on the physician's specialty, athletic trainers 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 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
Step 2 Select a Pilot Team.

Quiz Ref IDOut of 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 and their care team(s). Members of the pilot team should be trailblazers 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.

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:

Role Flexibility: Part of Practice Culture.

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 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.

Make Time for Team Members to Learn New Responsibilities.

Work with the physicians and team to remove less critical activities and waste. By reducing time spent on non-value-added work, that time can be redirected to have team members learn new skills. For example, have the medical assistant help identify needed preventive measures such as vaccines and cancer screening and pend the orders or bring to the physician's attention according to your protocols. 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

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 adaptability, openness, and innovation. 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 being exciting and fun, not burdensome.

  • 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 should be described as a nurse co-visit where the nurse manages preventive care and much of the chronic illness monitoring and education 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.2

    Some practices have trained medical assistants to document visits and manage prevention and illness monitoring by protocols or standing orders. 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 should be defined in accordance with your state's laws.

  • Under Medicare payment rules, can an RN document a patient's medication list in the EMR as part of medication reconciliation during an evaluation and management visit?

    Yes, where medical reconciliation (MR) is part of the review of systems (ROS) or past, family, and/or social history (PFSH) for the evaluation and management (E/M) service, under Medicare payment rules, the medication list may be recorded by any ancillary team, and then signed by the physician. Medical reconciliation is included in the Advancing Care Information performance category in the Merit-Based Incentive Payment System (MIPS).

Step 3 Develop Team-Based Care Workflows.

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 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, feel free to incorporate them into your future state. Try not to limit yourself; consider how an already great process can be made better.

Pre-Visit.

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 other team member. Some offices focus pre-visit planning efforts on only their patients with more complex care needs. Using a 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 one to three clinic days prior to the visit. Suggested processes for your pre-visit planning include:

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

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

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

  • Reminding 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.

Pre-visit planning activities and 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.

Day of Visit.

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 team members, the physician, nurses, medical assistants, 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.

What Does a Team-Based Patient Visit Look Like?

Quiz Ref IDThe nurse or medical assistant manages the first component of the visit, including updating the medical record, closing care gaps, and obtaining an initial history. These are part of expanded rooming activities.

When the physician joins the appointment, the nurse, medical assistant, or documentation specialist helps document the visit. When the physician portion of the visit is complete, he or she can review the notes, make any modifications, and sign the note. The physician is then ready to transition to the next patient's room while the other team members remain with the first patient.

The team member then emphasizes the plan of care with the patient and conducts motivational interviewing and education as appropriate. Use the ‘teach back’ method ensures patient understanding. The nurses and/or medical assistants become more knowledgeable about the treatment plan, can more effectively coordinate care between visits, and develop closer independent relationships with patients and their families.

Expanded Rooming.

In expanded rooming, the nurse or medical assistant is empowered to:

  • Enter certain elements, such as HPI, the Review of Systems (ROS) and Past, Family, and/or Social History (PFSH), and any part of the chief complaint (CC) or history for new and established office/outpatient E/M visits. However, the billing practitioner must provide a notation in the medical record supplementing or confirming the information recorded by others to document that the physician reviewed the information.4 Check your local, state, and professional guidelines/regulations.

  • Reconcile medications.

  • Provide immunizations based on practice protocols and state laws.

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

Team Documentation.

In team documentation, either a clinical person (nurse or medical assistant) or trained clerical person documents, or “scribes,” 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 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.

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.

Post-Visit: Today's Post-Visit Wrap-Up Begins the Next Visit's Pre-Planning.

Pre-visit planning for the patient's next visit should occur at the conclusion of the current visit. in addition to a discharge checklist, 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.

Expanded Discharge.

After the physician portion of the visit is complete, the nurse or medical assistant can either stay in the room or reenter to conduct expanded discharge responsibilities, such as:

  • Reviewing orders and instructions with the patient, conducting motivational interviewing to help patients understand what behavior changes are necessary to see desired results.

  • Printing and reviewing an updated medication list and visit summary.

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

  • Coordinating follow-up care by scheduling visits and corresponding laboratory work.

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. Physicians 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.

Ongoing Processes.

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.

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 medical assistants on the team. 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.

Box Section Ref ID

Q&A

  • Under Medicare payment rules, can non-physician clinic team members, 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, according to revised documentation from CMS, ancillary team members may enter certain elements, such as HPI, the Review of Systems (ROS) and Past, Family, and/or Social History (PFSH), and any part of the chief complaint (CC) or history for new and established office/outpatient E/M visits.4 This information does not need to be re-documented by the billing practitioner.

    Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that they have done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (HPI, Past Family Social History (PFSH), or Review of Systems (ROS)] for new and established office/outpatient E/M visits).

    However, the billing practitioner must provide a notation in the medical record supplementing or confirming the information recorded by others to document that the physician reviewed the information.

  • Can licensed team members 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 Medicare Administrative Contractor (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. Physicians should also check state, local, and professional guidelines.

Step 4 Implement Team-Based Care.

Prepare Your Pilot Team.

Now that you've designed your team-based care workflows, it's time to implement them. 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 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 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 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 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.

Keep the Rest of the Practice in the Loop.

Keep the entire practice informed of the change team's pilot work. Physicians and team members may feel out of the loop and disengaged if they are not involved.

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.

Don't forget to communicate the reasons why your change team elected to pilot team-based care in the first place:

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.

Quiz Ref IDIncreased 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 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 team members.

Estimate Savings From Team-Based Care.

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.

This calculator enables you to estimate the cost and benefit of implementing team-based care in your practice.
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. Remember: Try not to limit yourself; consider how an already great process can be made better.

Conclusion

Quiz Ref IDIn 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
Box Section Ref ID
Graphic Jump Location
AMA Pearls

AMA Pearls

Learn more about team-based care.

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

Sign in to take quiz and track your certificates

STEPS Forward™ presents actionable, practical toolkits and customizable resources that you can use to successfully implement meaningful and transformative change in your practice or organization. See How it Works

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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

ABMS MOC Statement: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Renewal Date: December 10, 2016; October 03, 2019

References
1.
Sinsky  C.A., Bodenheimer  T., (2019).  Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support.  Retrieved from http://www.annfammed.org/content/17/4/367.full.pdf
2.
Bodenheimer  T., Bauer  L., Olayiwola  J.N. (2015).  RN Role Reimagined: How Empowering Registered Nurses Can Improve Primary Care.  Retrieved from http://www.chcf.org/publications/2015/08/rn-role-reimagined.
3.
Centers for Medicare & Medicaid Services. (2012).  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.
4.
Centers for Medicare & Medicaid Services. (2018).  Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQs) Physician Fee Schedule (PFS).  Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-M-Visit-FAQs-PFS.pdf.
Close
Close
Close

Name Your Search

Save Search
Close
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
Close