To kick off the new year, CFAH is reprising some of Jessie's top blogs of 2013. After this post was originally published in February, it appeared on KevinMD.com where it received nearly 100 comments. What are your thoughts on team-based care? Let us know below and keep the conversation going.
Have you heard that soon most primary care in the U.S. will be delivered by teams?
Yep. Team-based care is one of the characteristics of the patient-centered medical home, a way of organizing the care of patients that allows primary care clinicians to see more patients in a day while at the same time delivering better care. This move toward team-based care started long before health care reform and was embedded deeply into the Affordable Care Act through its support for patient-centered medical homes and Accountable Care Organizations. It has been endorsed by the professional organizations of our primary care clinicians. There is a lot of activity directed toward making this the way most of us receive our regular health care.
What does this mean for us?
It's not clear. The growing literature on team care focuses mostly on the skills that primary care clinicians, professionals and office staff must learn and the changes they must make to deliver care as a team: how they should be trained, how the workflow is organized, how the group is led, how to build cohesiveness and trust within teams, how team members should communicate, etc.
How team care will affect us directly is sparsely described, but when it is, it is common to find promises that teams will coordinate our care among different settings (different specialists and hospitals, for example), that teams will pay more attention to helping us learning how to care for ourselves, and that we will have greater access to team members who can answer questions and help us solve minor problems. In a few papers, reference is made to "patients and families being members of the team."
Recently, I was asked to make some remarks about team care at a conference. Now, I have heard from a number of people over the years about their experience of being cared for by an oncology or cardiology team during cancer treatment or after a heart attack, for example, and they thought it was great being able to call the nurse, for example, and get quick, useful help. But I hadn't as yet heard much about people's experience with primary care teams.
So I asked ten people (regular ones, not health care experts) I encountered over the course of a couple weeks what they thought about the idea that "your regular health care would be delivered and coordinated by a team of people – your doctor and nurse and maybe a pharmacist and social worker and others, not just your doctor" meant for them. (Tiny sample, not representative, I know.)
Their comments clustered around three themes:
1) People were concerned that a team would make getting care less personal:
"Team care doesn't sound good. I just want my doctor to take care of me. I think this team care thing would get in the way of that."
"What, now they want me to know all these other doctors and nurses and aides and other professionals and to figure out that I have to call this one for this question and that one for that question? It's bad enough as it is. Sounds like the management consultants are running the show."
2) People were puzzled about what difference being cared for by a team would make.
"I'm a member of Kaiser Mid-Atlantic so I suppose I'm treated by a team. You'd think they would look at me as a whole person but I still go off to see the foot doctor and the hand doctor and the heart doctor and the only thing they share is my electronic health record."
"You know, they might have team care already for all I know. No one wears a name tag or tells me who they are or what their job is. I just shuffle around wherever they tell me."
3) I asked them whether they thought they and their spouse or someone else they chose should be members of the team.
"I don't think I should be a member of the team, but I should have the final say about my care."
"Are you kidding? I don't know what they know and all those different specialists and nurses talking about my problem? Nah. They have to organize it for me."
I too am puzzled about what team care means for us. When – and why – as a patient, do I need team care and what do I need to know about it?
Here are a few questions I – and many of my fellow patients – would like answers to:
First and foremost: Will I do better if my care is delivered by a team? Will my chance of having a good outcome improve? This is what I value. This is the bottom line.
And then, will my experience of my care be better – will I be more likely to participate in putting together a care plan that is realistic and acceptable to me – if I work with a team? For example:
- Will I have less contact with my trusted physician or will team care strengthen our relationship?
- Will team care afford me greater opportunities to understand my health problems and discuss my choices about treatment?
- Will team care mean there are more "rules" for me to follow to get help from my doctor? More gatekeepers?
- Will team care make it easier for me to get answers to my questions/prescription refills/appointments?
- Will my team coordinate my care so I don't have to?
I don't know the answer to these questions, but I can see that team care has the potential to affect positively or negatively both the outcomes of our care and our experience of it.
If shifting to team care means that our care will improve, why not tell us how. Explain (again and again) what we should expect from our team and help us understand how to take full advantage of the change. This is one way for teams to hold themselves accountable for their promises: tell us your goals and then ask us if you're meeting them.
And should we consider ourselves members of the team? Don't assume: ask for our preference.
For more information on this topic, see the Center for Advancing Health's Supporting Patient Engagement in the Medical Home.