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Monday Aug 13, 2018

Team-based Care Needs Greater Support

During my first year of medical school, I spent time volunteering at our student-run free clinic. About halfway through the year, I knew my way around the clinic and was confident in my skills, having gathered five patient histories and vitals.

[group of physicians and nurses in a circle]

On a particular Saturday, I strolled into the waiting room and called back the patient. She was a female in her mid-20s, a few years younger than me. She had come in just to get a work physical for a new job and had brought her 8-month-old baby with her.

Being a thorough, first-year student, I gathered all her medical, surgical, family and social history and performed a 30-point review of systems. During the review, she said her mood had been depressed for the past year. She was incredibly anxious because she had another child, who was not present, and her parents had kicked her out of the house. She was not married and was bouncing from one friend's home to another. She began tearing up, so I immediately grabbed some tissues for her and then sat there in silence trying to think of the right thing to say.

I had no magic cure for this person nor resources to offer. As a first-year student, I did not know what the best next step was for her. What I did know was that I had a psychology doctorate student available in clinic who was well versed in working with individuals with anxiety and depression. I let the patient know the psychologist was available, and she was interested in talking with her. I grabbed the psychologist, introduced her, and we had a good initial visit with the patient. When I left the room, I was confident we could help this woman manage her anxiety and depression.

Throughout my medical education there has been a strong focus on interprofessional, team-based care. First-year lectures covered team dynamics and conflict resolution. We broke into small teams and solved clinical problems. We were encouraged to participate in interprofessional case presentations. In my third year, I was able to apply these team skills when working with nurses, care partners, physical therapists, occupational therapists and pharmacists. This education prepared me for team-based care within the hospital.

Working on the palliative care team during my fourth year, I was able to participate in and observe a high-functioning team. For one patient, whom I will call Carol, we sprang into action to ensure that her goals were being met and respected. Carol was in her mid-50s and was diagnosed with lung cancer that had metastasized to her hips, spine and skull. She had undergone one round of radiation and was getting progressively weaker.

I met her when she was hospitalized after a fall at her home. She was in excruciating pain and did not know if she wanted to continue with radiation and begin chemotherapy. At the time she did not understand that those treatments were only palliative.

Within two days of meeting Carol, the palliative care team had a clear understanding of her goal: Spend time at home with her family for the next two weeks and then reassess her treatment options. Throughout the day, I worked with the fellow to coordinate with the family for a safe transition home, the case manager set up home palliative care, the nurse practitioners coordinated with the hematology/oncology team, and the attending worked on getting her pain medications filled. Carol was able to leave the hospital to spend more time with her family just a few days after the palliative care team was consulted because there was a team functioning together to achieve her seemingly simple goal.

Now as a resident at Saint Louis University, I am being trained on team-based care by spending a few hours with each of the various services offered within the federally qualified health center (FQHC) where I am working. I sat in on consults with our behavioral health; Women, Infants and Children; lactation; nutrition; and community health workers. I learned their skill sets and the best way to coordinate our care so patients can seamlessly see multiple practitioners in one visit.

My time volunteering in the free clinic, working with the palliative care team and shadowing the numerous services offered at the FQHC has prepared me to be a high-functioning member of a health care team.

Students and residents across the country are receiving a similar education.

For example, the Crimson Care Collaborative(crimsoncare.org) believes that the culture of medicine -- and more specifically, primary care -- must change to best take care of patients. Health care professionals need to build interprofessional trust and respect to meet all our patients' needs. The collaborative functions as a team of students and faculty across numerous professions that practice in a free clinic setting.

At John Muir Health,(www.johnmuirhealth.com) residents participate in at least two months of a team-based care clinic specifically targeted at instilling residents with the skills of being effective team members.

These examples are a small glimpse of the training that the next generation of health care professionals are experiencing. We are coming out equipped to thrive in settings such as accountable care organizations (ACOs) or patient-centered medical homes (PCMHs). The Patient-Centered Primary Care Collaborative 2018 report(www.pcpcc.org) reviewed 15 studies on the effectiveness of ACOs and PCMHs. The majority of these studies showed cost savings, and improved quality and utilization, and these new models of care are still in their infancy when compared to our fee-for-service system.

Students and residents, the future of family medicine, understand the value and importance of team-based care, its impact on our own well-being and the positive impacts that it has on patient outcomes. The Institute for Healthcare Improvement,(www.ihi.org) the AMA,(wire.ama-assn.org) and the AAFP all have a wealth of data on the impacts of team-based care. We have a well-trained family physician workforce to address the needs of patients and excel in the world of population health, but we do not have the payment model and infrastructure to support our training yet.

Our patients need hospitals and clinics designed to facilitate team-based care visits. Our patients need global payments for health care services, especially in the primary care setting, so clinics can provide access to physicians, psychologists, physical therapists, etc. for one cost in one location. This will simplify the world of primary care and improve outcomes for our patients.

John Heafner, M.D., M.P.H., is the student member of the AAFP Board of Directors.

Posted at 03:46PM Aug 13, 2018 by John Heafner, M.P.H.

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