Effective team-based care in family medicine: Success strategies
AAFP member Jennifer Bacani-McKenney, MD, on the perks of optimizing team-based care
Building strong team-based care, which can include hiring new team members and optimizing your workflows, is a strategy that can elevate your practice and patient care.
Your route to providing better patient access and more comprehensive care could be a new staff member and a few simple workflow adaptations away.
What is team-based care in family medicine?
Many practices engage in some level of team-based care. For example, at a basic level, physicians often work with nurses or medical assistants who help with tasks and patient intake. Teams are unique from practice to practice and can include roles such as care coordinators, health educators, nurses, behavioral health specialists and more.
Team-based care models help improve access, efficiency, coordination and even reimbursement in family medicine practices. By delegating administrative and care tasks to a team, family physicians can ensure they stay focused on what they need to focus on—the best medical care for their patients.
Benefits of physician-led care teams for patient outcomes
Medical team collaboration is meaningful to patient outcomes and patient satisfaction.
When physicians lead care teams, patients can have:
More time with their doctor
Support for making important lifestyle changes
Critical follow-up that reduces costs of care and improves outcomes
Better access to care when they need it
Importantly, patients strongly value their physician’s involvement in any team care. According to the AMA, nearly all patients believe a physician should be involved in their treatment decisions.
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How team-based care improves patient satisfaction and health outcomes
Team-based care models help patients feel supported and confident that they can get the attention they need. For example, when team members are connected to patients as part of a care management program, the direct outreach from office staff can prevent missed care.
Having team members in roles that help to reduce the amount of administrative work physicians have to perform in an office can also decrease how much attention a physician needs to dedicate to a computer during visits with patients.
Quality team-based care can also have major positive impacts on health outcomes. An article from FPM outlines several proven patient care results tied to various team roles, including:
Improved diabetes and hypertension outcomes when a pharmacist or chronic care manager is on the team
Improved depression outcomes when a behavioral health specialist or community health worker is on the team
There are many tools available to ensure that your team is prepared to deliver high-quality care, including a training module on improving diagnostic accuracy in a collaborative setting from the Agency for Healthcare Research and Quality (AHRQ).
How to implement strong team-based care in your practice
When you’re ready to advance team-based care by expanding services and programs and, potentially, adding new team roles, think about the needs of your practice and patient population. Try to focus on the most important goals you have. If meeting those needs requires more staff, some of the roles you might want to explore adding are:
A registered nurse care coordinator who can be a point of contact for patients or even help you jump-start a care management program if your practice has a large population of patients with multiple conditions
A population health navigator, social worker, clinical pharmacist, behavioral health specialist, nurse practitioner or physician assistant who can address a specific clinical or patient support need you’ve identified in your practice
Optimizing workflow efficiency through collaborative care models
Finding the right workflow makes it possible for your team to work to their full capabilities in coordination with each other. Workflows you might want to add or modify include the following:
Team huddles can improve communication and help the day run smoothly. Limit them to 10 minutes maximum, and make sure there’s a shared purpose and agenda. Keep in mind that allowing team members interested in taking on a leadership role to do so is an effective growth opportunity.
Panel management meetings are longer than a huddle and allow time for the team to review care for certain groups of patients and develop action steps.
Reimagined Medicare annual wellness visits can give the physician more time to focus on what’s important to the patient.
Pre-visit planning creates an opportunity to identify care gaps before an appointment.
If hiring new staff is not feasible, you can still improve team-based care by optimizing your existing team. Strategies might include realigning roles, redistributing tasks or expanding the role of a high-performing team member.
FPM offers seven tips for optimizing your team with the right workflow strategies.
A care team huddles before seeing patients for the day.
Best practices for health care team coordination and communication
Having a well-coordinated team requires strong communication skills and strategies. Getting everyone talking and working together effectively builds a strong foundation. Make sure you have a solid onboarding process and that you understand where your team members need training or might have knowledge gaps. Training and education across care team roles can be vastly different.
Strategies for effective communication among health care team members
Strategies for maintaining effective communication on a large team include: