As America's health care system continues its historic transformation, one of the primary features of the traditional hospital or outpatient clinic — physician-centric care delivery — is yielding to a striking new model: team-based care, in which physicians, nurses, social workers, pharmacists and others work together in new ways. While physicians may serve as the team leaders, they and the other team members share responsibility, authority and a mutual goal of improving quality while lowering costs.
"The real driver here is the move to value," says Brian R. Schuetz, program pirector at NEHI, a national health policy think tank. "Teams offer potential for significant value, both in cost savings from using less expensive practitioners, but also in better care because practitioners are suited for specific tasks."
In Atlantic City, N.J., AtlantiCare's team-based primary care for chronically ill patients has reduced hospital and emergency department visits by 40 percent. The smoking rate among its patients has fallen to 11 percent, patient experience scores have risen and overall costs have been cut by more than 10 percent. The model was so successful that AtlantiCare opened a second Special Care Center in Galloway, N.J.
At Brigham & Women's Hospital in Boston, team-based inpatient care has resulted in impressive reductions in inpatient mortality, significantly lower lengths of stay, and higher satisfaction for physicians and nurses.
The team-based model of care developed at ThedaCare hospitals in Wisconsin reduced costs per case by 25 percent in its first year — while patient satisfaction scores soared and readmission rates fell.
Those results are turning heads, but the widespread adoption of the team model will be slow, says John S. Toussaint, M.D., president and CEO of the ThedaCare Center for Healthcare Value. "The idea is something that everybody can believe in," he says. "But when you actually get into the details of trying to make it happen, most places are finding it to be extremely difficult."
Team care defined
Because the concept of team-based care still is quite new, there is no consensus on the ideal mix of roles and responsibilities to deliver top-value care. The team model at Brigham & Women's works differently from the ones at ThedaCare or AtlantiCare, but each organization shares the same goal.
"It means trying to dissolve the hierarchical, traditional structure that exists among nursing, physical therapy, pharmacy and medical staff, social work staff and others to empower individual members of the team to contribute equally to the optimal outcomes for the patients," says Graham McMahon, M.D., an internist at Brigham & Women's Hospital. He says that approach requires new processes, extensive training, cultural reorientation, and strong support from top administrators.
At Brigham & Women's Hospital and its sister Faulkner Hospital, a team-based model of care has been adopted for almost all general medicine units. It replaced what McMahon calls the "chaotic model," in which residents, attending physicians and interns rotated on different cycles; physicians and nurses did not know one another; and the admissions department assigned patients to whatever beds were available.
"Relationships were fractured and there was not real cohesion among people and, as a consequence, the ability to communicate effectively was limited," he says. "A nurse literally could be paging a doctor who was standing right beside her."
By contrast, each unit now has a team made up of attending physicians, residents, interns and medical students, pharmacy students and a faculty supervisor, nurses, a social worker, an RN care coordinator and a physical therapist. All members of the team are assigned to work together on a specific unit for at least four weeks at a time. That time limit reflects the need for residents and interns to rotate among many units for their training; in a nonteaching hospital, teams could work together permanently.
Two other key changes were instituted: The admissions department assigns a patient to an intensive care unit team only if there is a bed available on its unit and interdisciplinary rounds are structured sequentially by nurse, rather than by room number.
"It is an expectation that you don't discuss a patient until the nurse is present," says Ellen Clemence, R.N. "And it is an expectation that before a physician articulates the [patient's care] plan that you get the nurse's input. Either the attending or the resident always will address the nurse: 'Do you have anything to add about this patient?'"
The perspective of other team members is equally valued, depending on the patient's diagnosis and care plan. "Sometimes the most important clinician is the physical therapist," Clemence says. "The physician may be writing the orders and doing some of the direction, but I think it's really clear that the physician does not work alone."
Training a barrier
Brigham & Women's integrated teaching unit model was developed specifically as a way to improve physician training. But its use of teams is an outlier in health care training programs today.
That means health system leaders must reorient the way clinicians think about their work.
"Frankly, our health care professionals are not trained to be team members, they are trained to be individual heroes," Toussaint says. "What we have to do, basically, is undo all of that training, whether it's in medical school, in residency, nursing school, PT school, pharmacy school — and rewire the thinking process."
In some occupations, being a good team player is something that can be taught in an afternoon seminar, but not so in health care. "If we expect practitioners to work in teams, we really do have to expose and train them to work in teams," NEHI's Schuetz says. "It's not something that you can just, sort of, show up and do."
Writing in Health Affairs, Schuetz and two co-authors called for medical education to be reformed so that interprofessional training is the norm. "Bringing together students from multiple health professions for collaborative training is an essential bridge between the potential of team-based care and the realization of efficient care delivery and improved patient outcomes."
There are many barriers to that, Schuetz says, including a lack of communication across disciplines, conflicting academic calendars, separate faculties and too few practicing clinicians to model and support team-based care during clinical rotations.
Although a few universities offer collaborative educational programs in the health professions, the practice is not yet widespread. That fact was underscored when the American Hospital Association, at the request of the Accreditation Council for Graduate Medical Education, recently surveyed hospital leaders about the relative importance of the core competencies built into medical education and training.
"One of the biggest gaps was a team-based approach to care, and the need for physicians to actually understand teaming and understand the strength of their team members," says John R. Combes, M.D., senior vice president at the American Hospital Association. Combes oversees the association's Physician Leadership Forum, which is aimed at improving care processes, and launched in 2011 with a meeting focused on team-based care. "That exercise showed me that there is a clear recognition among CEOs that this is a very important aspect of care delivery in the future."
Combes sees team-based care as a logical element of high-value, patient-centered care. "This is part of a move to really transform how we deliver care — from care that's pretty siloed, that's pretty distant from the patient, that sometimes focuses on the technology and the knowledge base rather than on reaching the patient's goals," he says. "I think teaming as part of this new model of care becomes very, very important."
Lola Butcher is a freelance writer in Springfield, Mo.
AHA resource helps hospitals foster team-based care
The AHA's Physician Leadership Forum in February released a resource to help hospitals implement field-tested approaches to team-based care. The guide describes core concepts and how three organizations used team-based models to improve health care quality and efficiency: AtlantiCare Health System in Egg Harbor Township, N.J.; Boston's Brigham and Women's Hospital; and Marquette (Mich.) General Health System. While approaches differed, all had strong leadership, used data to drive and sustain change, taught participants to work as a team and used their passions to motivate them. Access the guide, Team-Based Health Care: Lessons from the Field, at www.ahaphysicianforum.org.
Who makes the team?
At the AtlantiCare Special Care Centers in Atlantic City and Galloway, N.J., primary care teams are built on two key principles: 1 Everyone operates at the top of the scope of their license and ability and 2 Everyone is accountable for all three parts of the Institute of Medicine's Triple Aim — improving the health of the population, improving the patient experience and reducing per capita cost of care.
The Special Care Centers are designed specifically to treat high-cost, chronically ill patients, many of whom have multiple medical issues. SCC Administrative Director Sandy Festa says staff members who work at the SCC view the "team" concept broadly. Because of the Triple Aim focus on population health, SCC teams include hospital case managers, work-site programs, health care purchasers and community resources. Because of its focus on the patient experience, individual patients are considered team members as well. "Patients either can walk toward health or they can walk away from health," Festa says. "We engage patients in walking toward a healthier way of life and give them the support to do so." Members of the clinical team include:
Health coaches: Each patient is assigned to a health coach and each coach manages about 150 patients. Responsibilities include educating patients about their conditions, helping them make appointments and navigate the system, and calling them if they show up at the emergency department.
Whether they are registered nurses, licensed practical nurses or medical assistants, health coaches work to their highest scope of practice. "You're responsible for those 150 patients. You room those patients, you have continuous contact with the patients," Festa says. "So we hear, 'I have to call Joe on Friday because I have to remind him … ' or 'Mary missed her appointment.'"
Physicans: Each primary care physician has a panel of about 800 patients — less than a third of the average caseload identified by the Medical Group Management Association. New patients are scheduled for hour-long visits.
To earn referrals from the Special Care Center, specialists must prove their willingness to play on a team. "We only use high-performing providers in our network — doctors who understand the care that we are providing, doctors who will consult us, doctors who will send reports to us when we refer to them and doctors who understand and are committed to the Triple Aim, including the patient experience," Festa says.
Those specialists typically come to the fore after Special Care Center leaders describe their system of care and goals. "A third of them say, 'Yes, I do that, too.' A third say, 'What are you talking about?' And a third say, 'Oh, my gosh, that's amazing,'" she says. "We connect with the 'Oh my gosh, that's amazing.'"
Working with high-performing specialists helped the SCC achieve two Triple Aim goals: improving population health and lowering costs. The team wanted to increase colonoscopies, but avoid some of the high costs typically associated with them. So they found gastroenterologists who were willing to use a generic prep that SCC stocks in its pharmacy and allow the SCC's primary care team to advise patients on preparing for the exam and relay the final results."We've eliminated the traditional pre-visit and the post-visit with the specialist by incorporating them into the patient's well visit," Festa says. "That's improving care and reducing waste."
Social workers and behavioral health providers: The team-based care model recognizes that life problems exacerbate health problems. AtlantiCare has found that 66 percent of SCC patients suffer from depression, anxiety or another behavioral health problem. "If we don't get that behavioral health under control, their chronic condition doesn't get better," Festa says.
Pharmacists: The Special Care Center boasts a medication compliance rate of nearly 98 percent, in part because an on-site pharmacy makes it easy for patients to pick up their prescriptions. If they fail to do so, the pharmacy team calls to remind them. "And we also get a report on who didn't pick up their medications, so then the health coaches reach out," Festa says. "It's a tag-team effort.
As president and CEO of the five-hospital ThedaCare Inc. system in Wisconsin, John S. Toussaint, M.D., spearheaded development of a team-based model of care that reduced medication reconciliation errors (to zero for more than four years) and reduced the cost per patient case, average length of stay and 30-day readmission rate while improving patient satisfaction. Today, Toussaint heads the ThedaCare Center for Healthcare Value, where he helps health care providers and purchasers create new models of care and reimbursement. His advice to health system executives who wish to implement team-based care:
• It never ends
A new care delivery model requires a cultural transformation rooted in a philosophy of continuous improvement. "If you think of this as a project, you might as well not even start because you will fail," he says. "This is a completely different way of doing business."
• Planting deep roots
Lean tools alone won't do it. Toussaint says the process improvement principles drawn from the Toyota Production System are important to help redesign processes, but developing a new care model requires change management expertise. "This goes deeply into the individual's belief system," he says. "Many organizations dabble in the Lean tools, but few understand the management system required for cultural change."
• Invest the time
At ThedaCare, organizational development experts worked with clinicians and administrators for six months to rethink their roles, responsibilities and interactions; then came six weeks of simulations using fake patients in a mock hospital unit. "These teams would go in and follow this new standard work for six weeks before we ever actually had a patient in the bed," he says.
• A modest beginning
Start slowly and use an experimental approach. ThedaCare started with a team of two hospitalists, two pharmacists and a group of nurses working on a 14-bed unit for 11 months before any decisions were made to expand the model to other units.
• Persuasive results
Give physicians the data they need. After its initial 11-month trial, the first team-based care unit reported no medication reconciliation errors and a 25 percent reduction in cost. And 95 percent of patients in the experimental unit gave ThedaCare an "excellent" patient satisfaction rating, up from 68 percent a year earlier. "The doctors looked at that and said, 'Wow, this is better quality at a lower cost, and the customers are more satisfied. I guess we're going to have to figure out how to get on board.'"