How Will This Toolkit Help Me?
Explains the essentials of a team-based care approach to care delivery
Describes telehealth advantages and opportunities
Specifies how to implement team-based care in telehealth
Physician-led team-based care (TBC) is a cornerstone of practice sustainability. Over the past decade, physicians and practices made great strides in developing and implementing team-based care models to support traditional in-office medical practice.1-6 In the spring of 2020, the COVID-19 pandemic accelerated the adoption of telehealth (virtual visits) among patients, health care professionals, and health systems.7 While beneficial for patient and care team safety and convenience, this accelerated adoption and growth of telehealth led many practices to revert to the “doctor does it all” model of practice—an approach that is neither sustainable nor effective. Given that the use of telehealth will continue beyond the public health emergency, it is important for practices and health systems to revisit and optimize their existing telehealth workflows.
What Is Telehealth?
Telehealth is a broad term encompassing a range of technologies and modalities that enable clinicians to provide health care services from a distance. Figure 1 provides some useful definitions.
Figure 1. Virtual Health Care Delivery Methods Covered by Telehealth
What Is Team-Based Care?
A team-based care model (Figure 2) is a higher-efficiency practice model designed to:
Improve the quality of patient care
Increase patient access to care
Improve care team efficiency
Improve satisfaction and engagement for patients and health care professionals
Figure 2. What Is Team-Based Care?2-5
A comprehensive approach to health care delivery transformation, including:
In this toolkit, we share team-based care workflows for synchronous telehealth visits based on recent institutional successes in the era of COVID-19. For more information on the adoption and optimization of telehealth in your practice, see the separate AMA STEPS Forward® Telehealth Integration and Optimization toolkit.
Four STEPS to Implement Team-Based Care Into Telehealth
Define and Engage the Team
Determine the Level of Team-Based Support Your Practice Is Able to Provide
Implement Team-Based Workflows
Assess and Optimize
STEP 1 Define and Engage the Team
Patient safety and quality of care benefit when teams leverage each other's skills and work together to complete the visit, and this is particularly true with telehealth. When building your team-based telehealth program, start with those team members you work most closely with every day. Identify and document current roles and how each contributes to patient care. Are there any gaps in roles that the practice needs to fill to proceed with implementing telehealth? Bring people together to discuss how to build a better way to care for patients. Value the perspective and experience of each person. Empower individuals in order to empower the team.
In addition to the physician, consider including:
STEP 2 Determine the Level of Team-Based Support Your Practice Is Able to Provide
The level of team-based support can range from Level 1,no support (“doctor does it all”), to Level 7, continuous in-room support including virtual rooming, pre-visit planning, real-time documentation support, and after-visit education and planning (the “ideal patient care journey”). Just as with in-person visits, where your practice falls on this ladder will depend on resources and staffing levels.
Figure 3. Levels of Team-Based Support for Synchronous Telehealth Visits
Ladder of Team-Based Support for Telehealth Visits (632 KB)
It is important to discuss with your entire team which “step” on the ladder will be most feasible. Commit together to give it a try, and learn from your collective experience, recognizing that you and your team can always make changes.
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Where should physicians conduct telehealth visits?
The flexibility of telehealth visits during the PHE is an advantage. Physicians can conduct the visit in an exam room, office, or at home. The ability for physicians to perform telehealth visits from their home is useful during mild illness (COVID or other viral infections that may be contagious) as well as for convenience and work-life integration.
What telehealth platform should we use?
Choosing or switching the right telehealth platform based on where your practice is on the ladder above is essential, as not all platforms will have functionality to accomplish the higher steps on the ladder, particularly if physicians and team members work from home (and are not co-located). The AMA STEPS Forward Telehealth Integration and Optimization toolkit has detailed information on choosing the optimal telehealth platform for your practice needs. Keep in mind that while some privacy and security regulatory requirements for telehealth services are waived during the PHE, these requirements may be enforced again in the future, which may impact the use of certain platforms.
A recent American Medical Association survey (PDF) revealed that physicians use a variety of platforms for virtual visits, as illustrated in Figure 4 below.
Figure 4. Surveyed Physicians Report Using A Variety of Telehealth PlatformsGraphic Jump Location
© 2022-2023 American Medical Association. All rights reserved.
How do patients react to having another person in the virtual “room”?
We have found that most patients accept and welcome the additional medical professional helping with their visit if the physician explains that the medical assistant is there to ensure accurate documentation, order entry, and follow-up so the physician can remain focused on the patient. Many patients even see it as an opportunity to have another advocate for their health care and develop close relationships with the assistant over time.
The introductory explanation is especially important for patients new to the team care process or new to telehealth. It may also be reassuring to let patients know that it is no problem if they want to be alone with their physician. In addition, if the physician or assistant senses that the patient is uncomfortable—such as during certain sensitive parts of the visit—the assistant may leave the virtual room.
STEP 3 Implement Team-Based Workflows
After you decide on the most feasible model on the ladder, develop and implement more detailed workflows. Look to adapt existing standard workflows as a starting point, and aim to mirror the patient experience with that of in-office encounters.
The process of developing a workflow should include:
Creating a workflow diagram with specific tasks and responsibilities associated with each step in the patient journey
Bringing the team together to discuss which role is most appropriate for each duty
Clearly defining and assigning the roles and responsibilities of each team member
Creating a Process Map (PPT) (859 KB)
Create a process map for your TBC telehealth workflow.
Two examples of telehealth workflows are illustrated below (Figure 5–Figure 6).
Figure 5. Level 5 Workflow for Telehealth Visit with Team Members Off Site
Example courtesy of VCU Health.
Figure 6. Level 7 Workflow for Telehealth Visit with Team Members In Office (Co-Located)
Example Workflows: Team-Based Care Virtual Visits (227 KB)
Use these examples of team-based care virtual visit workflows from Bellin Health and VCU Health to create a workflow that fits your practice
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How can this process be adapted for telephone visits?
It is ideal if supporting team members can initiate the visit, then hand off the visit to the physician. As with video visits, it is helpful if they can stay present to provide EHR support during the visit. This allows the clinician to focus on the patient without distraction and increases efficiency. The physician can leave the visit once they set the care plan, and the team member can then enter or pend necessary orders, schedule the follow-up visit if needed, and reinforce the plan with the patient.
STEP 4 Assess and Optimize
Come together for regular team meetings. Be open and honest; freely discuss what works well and what needs work. Keep each other accountable and willingly submit yourself to process-related and personal feedback. Be patient and show grace to one another as you navigate this change. When things aren't going as well as they might, try something different. Be flexible. Mix it up, and remember to write it down—what you did and how it went—so you know for next time. Don't forget to use patient feedback at every opportunity. Finally, celebrate your wins together as a team.
As you iterate and optimize your model, here are some telehealth Practice Pearls that we have found valuable from our experiences thus far (Figure 7).
Figure 7. Ten Practice Pearls to Optimize Your Telehealth Team-Based Care Model
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What strategies can we use to ensure continual improvement in new processes?
First, be willing to adjust your approach to best serve the team and, ultimately, your patients. It can be helpful to have whiteboards available so team members can write down questions or ideas for improvement. Ideally, feedback should be addressed daily. Regular care team meetings are also invaluable for reviewing the processes and workflows and getting ideas for refinement and ongoing improvement. Frequent check-ins like this help keep team members engaged.
One major effect of the COVID-19 pandemic was the accelerated adoption of telehealth. Telehealth has already proven to be a valuable patient care tool and gives clinicians another means to stay connected to their patients, with or without a pandemic. Early experience suggests that telehealth implemented without attention to workflow risks minimizing team-based care and introduces new barriers to efficient care. Therefore, practices should continue to adapt and build upon their experience with in-office team-based care as they develop new models of team-based care to support telehealth, even after the PHE is over.
Box Section Ref ID
Graphic Jump Location
Involve all team members in the creation of a meaningful and efficient workflow for team-based care in telehealth
Implementation does not have to perfect from the beginning; give your team members and your patients time to adapt, grow, and learn from the process
When practices incorporate team-based care into telehealth, physicians waste less time and telehealth productivity increases.
Journal Articles and Other Publications
American Medical Association, Manatt. Return on Health: moving beyond dollars and cents in realizing the value of virtual care. 2021. Accessed June 27, 2022. https://www.ama-assn.org/system/files/ama-return-on-health-report.pdf
American Medical Association. Telehealth implementation playbook. Accessed June 28, 2022. https://www.ama-assn.org/system/files/ama-telehealth-playbook.pdf
American Medical Association. AMA telehealth quick guide. November 5, 2021. Accessed July 19, 2022. https://www.ama-assn.org/practice-management/digital/ama-telehealth-quick-guide
Association of American Medical Colleges. Telehealth competencies across the learning continuum. March 2021. Accessed June 28, 2022. https://store.aamc.org/downloadable/download/sample/sample_id/412/
Centers for Medicare & Medicaid Services. List of telehealth services for calendar year 2022 (ZIP). Update June 17, 2022. Accessed June 27, 2022. https://www.cms.gov/files/zip/list-telehealth-services-calendar-year-2022-updated-06172022.zip
Centers for Medicare & Medicaid Services. State Medicaid & CHIP telehealth toolkit: policy considerations for state expanding use of telehealth. COVID-19 version. Accessed June 28, 2022. https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit.pdf
Centers for Medicare & Medicaid Services. State Medicaid & CHIP telehealth toolkit: policy considerations for state expanding use of telehealth. COVID-19 version: supplement #1. December 6, 2021. Accessed June 28, 2022. https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit-supplement1.pdf
Cleveland Clinic COVID-19 response digital health playbook. Cleveland Clinic. April 13, 2020. Accessed July 19, 2022. https://my.clevelandclinic.org/-/scassets/files/org/landing/preparing-for-coronavirus/covid-response-digital-health-playbook.ashx?la=en
Federation of State Medical Boards. U.S. states and territories modifying requirements for telehealth in response to COVID-19. Updated June 15, 2022. Accessed June 28, 2022. https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf
Hopkins KD, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21(6):23-29. https://www.aafp.org/pubs/fpm/issues/2014/1100/p23.html
Milford J, Strasser MR, Sinsky CA. TEAM approach reduced wait time, improved “face” time. J Fam Pract. 2018;67(8):E1-E8. http://www.mdedge.com/jfponline/article/170949/practice-management/team-approach-reduced-wait-time-improved-face-time
Sinsky CA, Jerzak J, Hopkins K. Telemedicine and team-based care: the perils and the promise. Mayo Clin Proc. 2020;96(2):429-437. doi:10.1016/j.mayocp.2020.11.020
Sinsky CA, Bodenheimer T. Powering-up primary care teams: advanced team care with in-room support. Ann Fam Med. 2019;17(4):367-371. doi:10.1370/afm.2422
Videos and Webinars
Hopkins K. Telehealth and team-based care: the shift to telemedicine and navigating potential pitfalls. American Medical Association YouTube page. Posted December 11, 2020. Accessed July 19, 2022. https://www.youtube.com/watch?v=QLDbJCjmFVA
Jerzak J. Telemedicine and team-based care: how to engage support staff to implement team-based care in telemedicine. American Medical Association YouTube page. Posted October 29, 2020. Accessed July 19, 2022. https://www.youtube.com/watch?v=kElozl7cxIU
American Medical Association. AMA Telehealth Immersion Program. Accessed June 28, 2022. https://www.ama-assn.org/practice-management/digital/ama-telehealth-immersion-program
American Medical Association. AMA telehealth policy, coding & payment. Accessed June 24, 2022. Last modified June 17, 2022. Accessed June 27, 2022. https://www.ama-assn.org/practice-management/digital/ama-telehealth-policy-coding-payment
American Medical Association. AMA telehealth quick guide. Accessed June 30, 2022. https://www.ama-assn.org/practice-management/digital/ama-telehealth-quick-guide
American Medical Association. COVID-19 telehealth guidance. Accessed June 30, 2022. https://www.ama-assn.org/topics/covid-19-telehealth-guidance
American Medical Association. CPT® Appendix T and Modifier 93: audio-only medical services. Accessed June 28, 2022. https://www.ama-assn.org/practice-management/cpt/cpt-appendix-t-and-modifier-93-audio-only-medical-services
American Medical Association. Telehealth resource center: research findings. Accessed June 30, 2022. https://www.ama-assn.org/practice-management/digital/telehealth-resource-center-research-findings
American Medical Association. Telemedicine: providing safe care during coronavirus pandemic (CME). Accessed July 18, 2022. https://edhub.ama-assn.org/course/281
Center for Connected Health Policy (CCHP) website. Accessed June 28, 2022. https://www.cchpca.org/
Centers for Medicare & Medicaid Services. List of telehealth services. CMS.gov. https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
Centers for Medicare & Medicaid Services. Telehealth. Last modified December 10, 2021. Accessed June 28, 2022. https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth
Mid-Atlantic Telehealth Resource Center (MATRAC). MATRC telehealth resources for COVID-19 toolkit. Accessed June 28, 2022. https://www.matrc.org/matrc-telehealth-resources-for-covid-19/
National Consortium of Telehealth Resource Centers website. Accessed June 28, 2022. https://telehealthresourcecenter.org/
Office of the Assistant Secretary for Preparedness & Response, US Department of Health and Human Services. Renewal of determination that a public health emergency exists. April 12, 2022. Accessed June 28, 2022. https://aspr.hhs.gov/legal/PHE/Pages/COVID19-12Apr2022.aspx
Telehealth.hhs.gov. For providers. Accessed June 28, 2022. https://telehealth.hhs.gov/providers/
US Department of Health and Human Services. Public health emergency declaration. Last reviewed November 26, 2019. Accessed June 28, 2022. https://www.phe.gov/Preparedness/legal/Pages/phedeclaration.aspx
US Department of Health and Human Services. Public health emergency declarations. Last reviewed May 9, 2022. Accessed June 28, 2022. https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx
US Department of Health and Human Services, Office for Civil Rights. Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. Last reviewed January 20, 2021. Accessed June 28, 2022. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
USAC Affordable Connectivity program website. Accessed June 28, 2022. https://www.affordableconnectivity.gov/
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