What is Team Based Care? Part 2

Yesterday we reviewed how care has been traditionally provided, even as far back as the ancient Greek physician, Hippocrates, and why with the ever increasing amount of Diabetes, High Blood Pressure and other chronic conditions, this model no longer works.

Team Based Care appears to be the answer. But what does this term mean? Here is the most basic idea behind Team Based Care:

Every patient is empanelled with one provider/care team and that provider/care team is continuously responsible for the care of a defined panel of patients.

Let’ take each part of this sentence and see what it means:
  • “Empanelled” means that each patient, usually based on their preference, is cared for by one provider/care team.
  •  “Continuously responsible” means that as much as possible, whenever a patient needs some form of care, the care is provided by that patient’s primary care provider or primary care team. The team is responsible for all aspects of the patient’s care, whether the care is initiated by the patient (e.g., patient calls or comes in because of a concern or a symptom), is initiated by the care team (e.g., patient is due for vaccine, exam, blood test or procedure), takes place in person (e.g., face to face visit), or virtually (e.g., phone call, letter, email, or text).
  • The “care team” would at minimum include a provider (physician, nurse practitioner or physician’s assistant) and a medical assistant, but might also include a front office worker, nurse, behaviorist (mental health practitioner), pharmacist or other trained individual. Each would be trained and responsible for a defined set of patient care activities, so that they are working at the top of their license or training. Most importantly, team members would work with the patient, and work together as a team, to provide the highest quality, most patient centered, most efficient care possible.
 Examples of role based care team activities would include:
  • Health Coaches working with patients to quit smoking
  •  Medical Assistants routinely screening patients for Tuberculosis through the use of provider written standing orders
  • RNs and/or Pharmacists using medication protocols to help patients adjust medications to better control conditions such as Hypertension, Diabetes or Asthma 
  • Front office workers calling patients to come in for vaccines that are due
  • Providers spending time to develop a care plan with, and to coordinate the care of, a medically complex patient
Receiving care in a time and place that is most convenient for us, from a person or team that knows us best, (and is the most capable person or team member to provide that care), and having a team watching our backs by reminding us when we are due for services.

Isn’t that what we would all like?
 
SFCCC partner clinics and health centers know that this is how they want their patients to be cared for and are working very hard to move towards this model.

So next time you interact with your health care provider, ask about Team Based Care.