Advancing to team-based care in the ambulatory enterprise

By Rick Roesemeier, MHA, senior manager, ECG Management Consultants, RRoesemeier@ecgmc.com; Paula M. Zalucki, MBA, FACHE, FACMPE, MGMA member, senior manager, ECG Management Consultants, PMZalucki@ecgmc.com; and Jyoti Mishra, MHA, senior consultant, ECG Management Consultants, JMishra@ecgmc.com.

It is often said that the whole is greater than the sum of its parts. In working groups, team performance can be much greater than the sum of each individual’s performance. In healthcare, improved performance is gained when providers are organized into groups — teams of clinicians and other staff working toward defined outcomes and processes.

Typically, inpatient-team-based care functions well, but the physician office often remains hierarchical, with the physician in a commanding role. The historical burden of all decision-making and the discretionary delegation of tasks flowing through physicians contributes to increasing administrative duties, leading to burnout. Nearly half of physicians report burnout.1

Team-based care presents a fundamental shift away from the physician-centric model by promoting all team members to work at the top of their license and capabilities to meet patients’ needs. Healthcare providers who advance to a team-based care model in the ambulatory setting enjoy higher staff satisfaction and retention.2 Team-based care’s stronger focus on preventive care, wellness and continuity of care allows organizations to be well positioned for value-based payments. Understanding the value proposition, fundamental characteristics and key enablers of team-based care is vital when considering it in your organization.

What is team-based care?

Team-based care refers to the delivery of health services through a multidisciplinary team working collaboratively with patients and their caregivers to achieve coordinated care with high-quality outcomes. Focused on shared goals across various care settings, team-based care promotes the shift from episodic care to comprehensive care in the ambulatory setting. Expanded team-based care models address social determinants of health (SDoH), including social services (housing, nutrition, adaptive equipment in the home), behavioral health, and wellness coaches and navigators.

The concept of team-based care does not merely involve adding more staff, but rather redistributing the work for improvements in patient outcomes and financial performance. Cultural change and careful transitions are required to advance to team-based care.

What makes team-based care different from other structures?

In successful team-based care, providers work interdependently instead of independently. While the physician is a leader of the care team, he or she does not hold an exclusive relationship with the patient. A comprehensive care team may include multiple physicians, advanced practice providers (APPs), behavioral health professionals, social workers, nursing staff and clerical support. Each member of the team is empowered to perform at the top of their license and communicate appropriate care instructions to the patient, according to the agreed-upon care plan. The team-based care model is reinforced to patients in communications, assuring them that each member of the care team provides value to their health.

Evolution of team-based care

Individual provider care delivery models (physician-centric)

Traditional physician-patient relationships were built on relational continuity, in which the exchange between the physician and patient builds trust over multiple episodes of care. However, this often results in the physician becoming the exclusive communicator to a patient, thereby consuming substantial physician time and reducing direct care time with other patients. The physician conveys lab results, changes in medication and guidance on self-care — tasks that can be accomplished by nonphysician care team members. In addition, processes are designed around the physician’s preferences and time, while support staff and patients conform to these processes.

Patient-centric care

Patient-centric care supports patients in learning to manage, organize and participate in their own care.3 The practice adapts to patient requests and convenience, such as hours of operation, modes of communication and care planning, which includes the patient in decision-making. Due to the involvement of the patient, many patient-centric care models ultimately evolve into team-based care, in which physicians delegate many tasks to other team members to optimize the patient experience.

Team-based care

Team-based care promotes patient-centric care because it is designed to be more comprehensive and accessible to patients.² Implemented well, it can enhance efficiency and effectiveness through improved access and promote comprehensiveness and coordination of care. However, the transition to team-based care often requires a reorientation of roles and responsibilities and how providers interact among the team and with the patient. Team members should be authorized to convey information to the patient, instead of channeling all patient communications through the physician.

Why team-based care?

Team-based care is designed to achieve efficiencies in care by optimizing each team member’s time while focusing on effectiveness and value for the patient. Specific characteristics of a team-based care model include:

• Empowered team members operating at the top of their license
• Patient involvement in medical decision-making, promoting accountability for their health and wellness
• Support for new approaches to case management and chronic condition management, yielding reductions in the cost of care
• Greater focus on transitions of care and care planning.

Healthcare organizations that have fully adopted the team-based care model report improved patient outcomes, specifically achieving value-based care incentives, such as avoidable inpatient utilization. The quality benefits of team-based care are demonstrated by the results of a longitudinal study done at Intermountain Healthcare, measuring 113,452 patients who received care either at a team-based or traditional medical practice.⁴ Intermountain found that team-based offices screened patients for depression at a higher rate than traditional offices, diagnosing almost double the number of patients with active depression. In addition, team-based care helped approximately 5% more patients adhere to diabetes protocols. Patients participating in team-based care had lower rates of emergency department (ED) visits and hospital admissions.

Strategies for evolving to team-based care

Cultural, operational and financial barriers exist in the typical ambulatory environment that impede the successful deployment and adoption of team-based models. The topics and strategies below are crucial in creating support for this model.

Provider compensation and incentives

Historical characteristics. Encounter volume has long driven the economics of ambulatory practice. Correspondingly, organizations have incentivized physicians and providers with volume-based measures and metrics typically based on individual activity (e.g., work RVUs [wRVUs], panel size). This compensation model discourages providers from forgoing face-to-face encounters in favor of alternatives, such as telephone calls or visits supported by their care team. As a result, patients often wait to be seen based on the provider’s availability, likely to lower patient satisfaction.

Forward-thinking strategy. Establishing team-based volume and value incentives can alleviate this barrier. A team-based approach balances the distribution of responsibilities, allowing providers and staff to work at the top of their license while completing clear and consistent handoffs. Aligned reward systems should include metrics and measures to evaluate performance toward common, team-based goals. Introduction of these incentives is a required competency of high-performing healthcare organizations.

Organizations must carefully consider the timing and approach when transitioning compensation incentives from traditional models. A phased approach over multiple evaluation periods, with increasing quality and team-based goals, is often less disruptive than a sudden overhaul in compensation. This transition may be facilitated through an established physician governance committee engaged in the identification and definition of goals and enterprise-wide processes to allow for stronger adoption of new metrics and compensation models.

Workflow design and EHR configuration

Historical characteristics. Ambulatory clinic workflows often are not standardized and are typically oriented around the preferences of each provider. Because the needs/demands of each provider’s processes are inconsistent, support is often inappropriately aligned with the provider needs and workflows, therefore placing the provider at the center of all activities. Further, the EHR is rarely optimized to facilitate each set of provider-centric workflows, instead relying on generic configurations with limited workflow and communication support.

Forward-thinking strategy. Develop common workflow activities built around team-based roles and responsibilities. Integrating these new workflows into the EHR using automated communication routing supports handoffs, hard-codes new processes into the practice and facilitates greater consistency in care team activities.

All members of the care team should participate in the future-state design process. With careful consideration toward elevating the roles of support staff and scrutinizing the tasks and activities of providers, ensure that each workflow includes specific instructions and standards to support information exchange and handoffs. Many organizations have found small pilots or testing of changes to be a successful method to refine new workflows and support adoption with data. Once defined, workflows must be clearly documented and communicated to all members of the team.

Recognition and acknowledgment of physician burnout

Historical characteristics. Many organizations and physicians have attempted to address symptoms of burnout through reduced clinical time and/or flexible schedules that become difficult to support operationally. As administrative tasks and documentation requirements have grown, providers have continued to dip into patient-facing hours to meet the typical work expectation.

Forward-thinking strategy. To help combat the causes of burnout, the team-based approach removes the provider from unnecessary workflows and communications and more evenly distributes the burden of panel and patient care management across a team of caregivers and support staff. As indicated, establish workflows that reassign unnecessary activities from the provider, and train staff accordingly; further, integrate these roles into the configuration of the EHR and operations support applications to maintain compliance/adoption. Providers remain at the core of clinical decision-making; however, clinical protocols and standards help to better utilize clinical support staff to respond to patient questions/​inquiries in a timely manner without burdening the provider. This transition is often incremental, with providers handing off high-priority tasks (e.g., normal lab and imaging results notification and/or maintenance dose prescription refills) over time as they recognize the value and develop trust within their teams.

Patient access

Historical characteristics. Patient access metrics are important performance measurements of efficiency and how community demand is met. Though investments in administrative infrastructure for scheduling and shared service strategies often are made, most providers have not recognized poor performance in scheduling as problematic and often wear long patient wait times as a badge of honor relative to the demand for their services.

Forward-thinking strategy. Forward-thinking organizations challenge the physician-centric patient care model and introduce new capacity through alternative care models (e.g., online assessments, virtual visits, APPs conducting follow-up visits), as well as education and triage from clinical care teams. Set a patient access strategy with clear goals, expectations and accountability to push providers and operational leaders to challenge the historical model. In concert with the evolving compensation system, incentives for improved patient access and clinical outcomes become drivers for team-based care success. A focus on reduced wait times for appointments and reductions in ED visits and hospital admissions can be achieved through a support staff’s enhanced role in communicating with patients.

Scope of practice

Historical characteristics. Medical group leaders often rely on the perspectives/opinions of caregivers to interpret the scope of practice of clinical care team members. This leads to variation across the organization and often across providers within the same clinic. The “it’s my license” comment is often a barrier to progress toward collective solutions that enable support team members to function similarly across the ambulatory enterprise.

Forward-thinking strategy. Medical group leaders should educate themselves on current state, federal and payer-specific regulations related to scope of practice for both nonphysician providers (NPPs) and nonlicensed staff. This is particularly relevant as COVID-19 emergency rules have allowed APPs to work without immediate physical supervision. While the future is uncertain, this is anticipated to influence APPs’ future scope of practice regulations and recognition from payers as billable providers.

Care team staffing

Historical characteristics. Turnover among clinical and nonclinical support staff members has been an accepted reality in many organizations. Staff are not presented with the ongoing training and growth opportunities necessary to cultivate long-term employees with escalating levels of competency and value to the organization.

Forward-thinking strategy. Clearly documenting roles, responsibilities and growth plans for clinical and nonclinical support staff positions recognizes the value of these team members and bolsters staff retention. The organization can establish clear expectations with experienced staff and cultivate the trust needed to transition to a team-based care model. Clinical and operational leaders within the organization are responsible for maintaining staff development programs and making this effort a priority for staff and the organization. As physician enterprises grow, some have begun to establish teams and/or nursing and administrative leaders directly responsible for the training and development of support teams, similar to their acute care counterparts.

It’s time to realize the value of team-based care

Team-based care is no longer a progressive model of the future — it is the required model of the present. Patients are demanding convenient access to care that cannot be supported by the historical, physician-centric model that relies solely on in-person physician encounters and communication. High-performing care teams composed of clinical and support staff capable of efficiently and effectively responding to patient care needs and requests in a timely fashion present a competitive advantage relative to patient acquisition and loyalty. Further, organizations that deploy these teams will enjoy improved staff satisfaction and retention as well as a stronger value- and/or risk-based contracting position. Physicians engaged in team-based care become less burdened with administrative tasks and can concentrate on the patient care activities for which their training and license is required.

The transition to team-based care models should not be taken lightly. Several cultural and operational attributes should be considered and must be planned for appropriately to facilitate the change. Organizations that have successfully made this change have recognized these considerations and prepared accordingly. Establishing a physician governance committee to drive discussions on cultural changes, standardize processes, establish goals and gain consensus is a critical step on the path to success.

Notes:

1. Berg S. “Physician burnout: Which medical specialties feel the most stress.” AMA. Jan. 21, 2020. Available from: bit.ly/3mkaTMy.
2. Coleman K, Reid R. “Continuous and Team-Based Healing Relationships: Improving Patient Care through Teams.” Safety Net Medical Home Initiative Implementation Guide Series. 2013.
3. AHRQ. “Defining the PCMH.” Patient Centered Medical Home Resource Center. Available from: bit.ly/3mnRgD9.
4. Reiss-Brennan B, Brunisholz K, Dredge C. “Association of Integrated Team-Based Care with Health Care Quality, Utilization and Cost.” JAMA. 2016; 316(8):826–834. doi:10.1001/jama.2016.11232.