Welcome to Care Coordination and Interoperable Health IT Systems, Team-based Approach to Patient Care. This is Lecture a- Multidisciplinary Care Planning. This unit will explore innovative patient centered, team-based care delivery systems transformation. The objectives for this unit, Team based Approach to Patient Care, Lecture a, are to identify best practice types of team-based interventions, and describe key elements for transforming to team-based care. What is Team-based Care Coordination? According to Naylor, Coburn, and Kurtzman, team-based healthcare is the provision of health services to individuals, families, and or their communities. By at least two health providers, who work collaboratively with patients and their caregivers, to the extent preferred by each patient to accomplish shared goals within and across settings, to achieve coordinated, high-quality care. Team-based Care Coordination involves collaborative team partnership relationships, ensures defined, structured processes, and encourages continuous quality improvement, and best practice tools used for collaboration, coordination, and communication. Why practice Team-based Care Coordination? Team-based Care helps develop relationships around the care of our patients. Team-based patient care helps in the transition between the entities of the health care systems. Transferring critical information for critical decisions at the point, and time in care, when physicians need it most. When do we need Team-based Care Coordination? Team-based, patient-based care transitions over time, as information transfers and/or responsibility shifts. For example, between episodes of care, I.e., a patient's initial visit and follow up visit. Coordination is also needed across a lifespan, i.e., pediatric developmental stages, women's changing reproductive cycle, or geriatric care needs. Care must also be coordinated across the trajectory of illness, and changing levels of coordination need. Who is involved in Team-based Care Coordination? Team-based Care Coordination happens amongst members of one care team, for example, from reception to nurse to physician, and also between patient care teams. Care is also coordinated between patients and informal caregivers, and professional caregivers, across settings. Primary care to specialty care, inpatient and emergency department, and between health care organizations. Collaborative Team-based Care models are highly desirable for advanced collaborative interventions, where the team's action and processes prove to successfully meet target interventional goals that support the Quadruple Aim in national health care reform. These aims are, to improve individual patient health experience, population outcomes, lower costs and improve health care clinicians' experience. Developing the high functioning team for Team-based Care interventions requires defining collaborative roles, responsibilities, and accountabilities tied to delivering care and interventions through standardized processes that embed evidence based guidelines. Healthcare information technology systems can capture health information to enhance the ability to measure and trend data, and precisely manage interventions, and improve outcomes for specific target populations. This includes preventive health outcomes and chronic health outcomes. Because Team-based Care interventions reduce costs in care and improve health outcomes, Team-based Care is the preferred new model of primary care delivery. Examples of health care reform models of care that adopt Team-based Care delivery principles include advanced primary care models, patient-centered medical home models, accountable care models, community care models, shared savings models, bundled reimbursement models, and etc. Team-based Care Models, such as the Patient-Centered Medical Home (PCMH), are a critical foundation, and highly desired in the healthcare delivery, value driven models of care. The standardized learning in technology systems-based collaborative infrastructure, drives evidence based patient-centric interventions, using a high functioning health care delivery team with well defined roles, responsibilities, and accountability. A traditional physician's practice had fractured care delivery. Composed of silos, where functional areas of the practice did not have an understanding of the entire office workflow, and how one's role interacted with others. Thus Team-based Care delivery, as the hallmark of the Patient-Centered Medical Home model of care, allows everyone in the practice to collaboratively play a vital defined role. Each team member has responsibility and accountability in caring for the patient. The Team Approach brings an understanding of all practice operations, where the practice team can address inefficiency and continuously improve. Essentially, the teams become more integrated, more involved at every level of implementation, are responsible for team member specific roles, and having a demeanor to share information, and have their colleague's back in any situation. The patient is a vital part of the team. The team is patient-centered where the patient and family, when appropriate, are active members in their care by sharing in decision-making, and collaboratively learning more about self-care management through team care coordination. In team-based care roles, responsibility and accountability for information and care delivery is spread across the team collaboratively under the team leadership of the ordering and referring physician, ultimately responsible for the patient's care by the whole team. Multidisciplinary collaborate team members combine their aggregate experience, knowledge, intellect, and expert skills to optimize coordination and delivery of comprehensive healthcare, aimed at providing the best possible outcome for the whole person, physical, and psycho-social needs of a patient and family when appropriate. As patient and family needs change with time, the composition of the team will also change to meet whole person needs. The patient and family, when appropriate, are a part of the team and participate in shared decision-making. As the team leader, the team is at times expanding across care settings, wherever and whenever the patient needs and chooses care. Collaborative team leadership, communication, teamwork and informatics roles can spread to the expanded multidisciplinary team to collectively address complex special needs, collaborative and coordinate care, for the best possible outcomes. Multidisciplinary Team Members can come from many healthcare disciplines to collaborate and partner for patient centered care coordination. It includes hospitals and integrated systems clinical, emergent, urgent care centers/facilities and EMS/paramedics, medical specialists, maternity and women and children's health. Financial, education, quality improvement, safety, and infection prevention teams. Behavioral/mental health services. Pharmacy and medication management services. Physical therapy and rehabilitation services. Case management services, post-acute care programs and services, care transitions, and social workers. Community-based services, Chaplains, Patient and Family Advisory Councils, and Patient and Family Advocates. This concludes Lecture a, Multidisciplinary Care Planning of Unit 2: Team-based Approach to Healthcare. In summary, this lecture covered Team-based Care as a proven, preferred model. Trusting relationships and mutual respect are fostered among team colleagues. Patients and families are a part of the team. Patient and family needs change with time, so the composition of the team will also change to meet whole person needs. The patient and family, when appropriate, participate in shared decision making. Multidisciplinary collaborative team members combine their aggregate experience, knowledge, intellect, and expert skills.
