You have seen it as a trending topic, primary care practices are talking about it, you’ve heard that change is coming, but what is team-based care anyway?

Team-based care has many name variations such as, coordinated care, patient-centered care, interdisciplinary care, collaborative care, to name a few. No matter what you call it, team-based care is a delivery model that puts the patient at the center and has these components.

  • The deliberate organization of care activities between 2 or more participants
  • Care that is relationship-based, focusing on the whole person
  • A partnership with patients and their families/caregivers
  • Care delivered in a way that respects each individual’s unique needs, culture, values, and preferences
  • Allows each patient to have a choice in managing their health conditions and participate in their care

Team-based care allows healthcare teams to work together to deliver the right amount of care by the right clinician at the right time. This concept has been evolving for decades with early documentation as far back as the 1990’s when chronic diseases became something that needed more attention. In the early 2000s, there was an initiative called, Transforming Care at the Bedside (TCAB), and held some of the same principles as today’s team-based approach. Moving between 2007 and 2017 came Triple Aim, the designation of Patient Centered Medical Homes (PCMH), the formation of Accountable Care Organizations (ACO), and finally Quadruple Aim. All of these milestones are propelling us forward into a more integrated care approach.

The core principles of team-based care include: 

  • Shared goals
  • Clear roles
  • Mutual trust
  • Effective communication
  • Measurable processes and outcomes

It starts with a shared goal.

In team-based care, all care team members must be working towards the same clearly defined purpose, in sync with one another. This includes the patient, the provider, and other caregivers. Care teams are typically made up of the primary care physician, nurses, medical assistants, and extends to health coaches, social workers, behavioral health specialists, and even pharmacists.  

Everyone must understand their responsibility and have accountability for their part in achieving the desired outcomes. When everyone is operating as a unit it fosters trust, and trust supports efficiencies.

When you can count on your team to do what they say they are going to do, patient flow and other processes run smoothly.  Administrative work can be divided and delegated away from the provider according to knowledge and licensure of each care team member, freeing up the physician to do what they do best, which is practice medicine. With strong communication skills, teams can more effectively serve patients with added attentiveness and fewer errors. In this model of care delivery, norms are set, and everything is measured as teams strive for continuous improvement.

As an employer, why should you care?

Quality care is a top priority for healthcare systems. When your entire team comes from different disciplines helping them establish a common operating language is crucial to this model, but it takes time. Standardizing training on these interdisciplinary teams and using an assessment to measure knowledge of the process can help ease the discomfort that comes with transformation. Remember, it is a marathon, not a sprint.

Change is hard, and your teams may be reluctant to work so collaboratively. It can sometimes feel like they are giving up control of tasks that they have routinely managed. But many times the results will outweigh the challenges with cost savings, happier and healthier patient panels and even restore joy in practice for the care team.

As an educator, why should you care?

As educators, you are invested in our future healthcare professionals. This not only includes teaching clinical competencies but also teaching essential soft skills such as communication, active listening, empathy and understanding patient’s needs. These same foundational principles are the very basics of practicing in a team-based environment.

By equipping candidates with the appropriate mix of skills, you can help them become work-ready so they are productive members of the care team very early in their employment journey. It is no secret that healthcare is moving towards patient-centered models, so by pushing your learners to strive for certification, plus have an understanding of this care continuum they become more marketable.

Most importantly team-based care helps everyone find their sense of purpose because their job matters to their care team and to their patients. We are on the journey together to make healthcare more affordable, more effective and our health goals more reachable.

Learn more about TEAM Based Care






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