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 director 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 among 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 & Wom-en's works differently from those at ThedaCare or AtlantiCare, but the organizations share 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 any available beds.
"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."
Undoing Traditional Training
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 and president and COO of the Center for Healthcare Governance. 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," he says.
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.
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