Coordinated Patient Care
Team-based care is a hot topic in the lexicon of modern medicine. It refers to care provided by a coordinated team that can include physicians, allied health professionals (AHPs) such as nurse practitioners, and others. Team-based care is a cornerstone of healthcare delivery system reforms and integral to patient-centered medical home recognition. The premise is that team members working together can deliver more efficient, more cost-effective care to patients.
Team-based care isn’t just for ambulatory care—the team approach has been implemented in acute and sub-acute environments, and for managing chronic conditions in hospital settings. As millions of Americans obtain health insurance and access ongoing healthcare under the Affordable Care Act, physician-led teams can help meet that surge in demand for services, the AMA states. Advocates for physician assistants and nurse practitioners make the case for teams led by AHPs.
Determining who leads the team need not be a battle, but practices must consider patient needs, team members’ licensure limitations, state and federal supervision, and collaboration requirements, as well as reimbursement issues. Teams should also strive to develop a workflow plan that can make the most of team-based care and achieve desired results.
For many practices, the first step is determining which practitioners should see which patients. The Institute for Healthcare Improvement and others recommend that all providers in a practice—including physicians, NPs, and PAs—have their own panel of patients, rather than delegating certain visit types to nurse practitioners and physician assistants. For example, sending only certain types of patients to NPs might increase the chance that other conditions might be missed.
Once workflow is established, healthcare teams need to measure care processes, be it for optimal care, compliance with state and federal guidelines, or maintaining certification for PCMH, accountable care organizations, or other initiatives. Measuring processes also enables a practice to understand overall team performance, workloads, and productivity. As Ted Quinn wrote in a widely cited MedCity column earlier this year, high functioning teams know how to find an answer the question, “how is care happening?”
Effective communication is imperative to finding that answer. A robust EHR will accommodate various modes of collaboration, via an internal messaging system or simultaneously, even if some team members are looking at charts remotely.
Optimized care teams give back valuable time to physicians and nurses. Freed from the to-do list that doesn’t match their skills, care providers have more time to provide care.
Implementing team-based care should done gradually, and every day will not be perfect, the AMAcautions: “Be patient; know that several months may go by before the team feels like they are really gelling in their new system.”

Last Updated on June 29, 2016