How Team Based Care Works with Primary Care Patients

Does your medical communication involve your patient’s other healthcare experts to provide team-based care? For various reasons, patients often seek treatment from different healthcare specialists, and you may not be aware of all of them.

For example, if a patient had oral surgery and was prescribed a strong painkiller that made them feel sick, they would most likely go to their primary care physician for answers. Certain painkillers and medications may have side effects that impact one’s mental health and can leave a patient feeling depressed. If that were the case, they may want to talk to a psychiatrist. 

This is why physician-led team-based care is an important strategy. It enables health care practitioners to create the most effective and efficient solutions for the patient. Let’s look at how team-based care approaches are used, while exploring ideas for your medical organization.

What is Team Based Care?

‘Team-based care’ is a method of connecting multiple healthcare providers in order to meet a patient’s needs by utilizing collaborative communication. Nurses and advanced practitioners lay the foundation for this value-based care by providing necessary communication between different practices and hospitals. 

A patient’s primary care provider can communicate with their cardiologist if they’re experiencing chest pain and need to be admitted to the hospital, but it’s  usually nurses who tend to be on the front line of this medical communication. They bridge the gap between specialists. Medical assistants often step in and fill this gap for physicians too, giving time back to doctors so they can focus on patient care needs while unloading some of their more administrative tasks.

Team Based Primary Care Approaches

The Old Care Model

Clinical patient treatment has traditionally followed a transactional, one-and-done, provide-a-diagnosis-and-get-reimbursed approach. With this model, physicians may be incentivized to have a particular service or procedure rendered within a narrow scope. They may not receive reimbursement for time spent coaching, listening to, and educating the patient through more intangible means. With this pressure, the physician may overlook other health issues the patient could be experiencing.

To be clear, patient health has always been a top priority in the medical field. However, the old model mostly makes room for “traditional” healthcare practices like meeting the patient, rendering a diagnosis, and giving treatment. In the new team-based care model, doctors focus on coming together to take a more holistic approach versus a single, isolated diagnosis and treatment for their patients. However, under this model, several challenging factors can arise, such as reluctance to communicate due to the inconvenience and potential time constraints among multiple providers.

“The five most common challenges that face healthcare teams relate to accountability, conflict management, decision-making, reflecting on progress, and coaching. These challenges were similar across both clinical and administrative team types.”¹

Patients who don’t proactively share the full scope of treatment they’re receiving can cause challenges for clinicians and medical practice leaders. Patients may not share with their primary care doctor that they are also seeing a psychiatrist, neurologist, or other specialist. When each physician flies solo without collaborative communication, they’re not able to make the most informed care decisions based on the patient’s complete treatment regimen.

The New Team Based Care Model

The new team-based care approach requires a holistic change in workflow management that improves the value patients extract from the care they receive. With the patient’s permission, it can provide an environment where multiple practitioners and specialists share information, responsibilities, and delegate tasks. Having a medical assistant, nurse, physician, or specialist assess and gather patient information ahead of time and during patient intake can help improve a patient’s experience.² 

Consider updated digital workflow tools to improve the patient experience. Gone are the days of passing around clipboards and sticky notes for room rotations and patient updates. As one example, sending follow-up messages, educational materials, and other information via modern technology systems that use text messaging can accelerate speed to care and improve patient engagement.

Physician Led Team Based Care: What Works?

When healthcare executives involve physicians, physician assistants, and nurse practitioners in the decision-making process, patient satisfaction increases. The main priority should be the patient’s satisfaction and comfort. How is this accomplished?

It’s only natural for some providers to feel like their own practice and field is “the best.” However, when it comes to the patient, their health and wellbeing are the main priority. If the opportunity presents itself, it’s vital for all providers involved in the patient’s care to communicate with one another, because one medication or method for diagnosis may affect another symptom the patient is experiencing.

Ineffective Team Based Care

As one example of an ineffective approach to patient care, what this “couples therapy” video about cardiology and nephrology. It’s a comedic take on approaching team-based care.

In this skit, the specialists let the real issue escape them because they’re more concerned with who’s right. 

Although team-based care provides patients with multiple professional opinions and solutions, it can still be confusing. When healthcare professionals from different fields come together to focus on one issue, there is a shared level of responsibility they must accept. Having this responsibility can sometimes lead to irrelevant disagreements, which takes attention away from their main focus—the patient’s needs.

What Performing Team-Based Care Providers Are Doing

Organizations like Health Advocate take a look at all factors that may affect their patients. Instead of focusing on the diagnosis alone, they take the time to show empathy. It’s not just about finding a quick and easy solution—it’s about asking questions that dive deeper into the patient’s issues which could include other factors like finances, mental health, and overall stress.

“Our Health Advocacy service serves as the integrator for all healthcare and benefits needs. Our Personal Health Advocates will direct people to other experts on our team or coordinate with your benefit vendors to create a seamless transition.”³

Solutions like HealthMap focus on bringing multiple providers together to help those with Chronic Kidney Disease. They may incorporate dieticians and skilled practitioners to align with the nephrologist. Since each patient is unique with comorbidities, their care must be customized to fit their specific needs.

“We partner with patients’ providers, such as primary care physicians, nephrologists, cardiologists, and endocrinologists, to support and manage the ‘whole’ patient in our Kidney Population Management program.”⁴

Other healthcare teams might take a few minutes each day to align medical staff around that day’s priorities and incoming patients. Here is one example of a medical group aligning priorities and communicating effectively:

Team-Based Care Strategies for Your Organization

Is it time to rethink your patient care model? If ensuring optimum collaboration across all specialists in a patient’s orbit isn’t on your radar, it should be.. A few benefits of rethinking and optimizing your patient care strategies:

• An organized process leads to true valued-based care. 
• Having balanced, professional opinions benefits the patient.
• Patient education initiatives get them more involved in their own care.
• Regular, updated communication between provider and patient builds mutual trust.
• Better processes and technology lead to decreased workloads for medical staff.

Read how other medical practices are teaming up to deliver exceptional patient care outcomes.

¹Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance, Frontiers in Communication, March 17, 2021. https://www.frontiersin.org/articles/10.3389/fcomm.2021.606445/

²Kevin Hopkins, MD, on challenges to team-based care: COVID-19 & beyond, American Medical Association, April 7, 2021. https://www.ama-assn.org/practice-management/scope-practice/kevin-hopkins-md-challenges-team-based-care-covid-19-beyond

³Health Advocacy is the heart of what we do, Health Advocate, 2022. https://www.healthadvocate.com/site/our-approach

⁴Healthmap Solutions, 2022. https://hub.healthmapsolutions.com/for-patients