Welcome to Care Coordination and Interoperable Health IT Systems, Team-based Approach to Patient Care. This is lecture b, Transformation Planning. This unit will explore the plans for transformation to team-based care. The objective for this unit, Team-based Approach to Patient Care, Lecture b, is to plan for transformation to team-based care, develop multi-disciplinary team driven care planning. The transformation plan teamwork incorporates five key elements of team building. Establishing clear goals with measurable outcomes. Clinical and administrative systems. Divisions of labor, training, and communication. From the beginning of a team-based care transformation, integrate the patient-centered medical home recognition standards checklists into the transformation plan. Over time, fully implement elements from the Patient-Centered Medical Home standards and criteria using evidence-based best practice tools, resources, and adapt processes that work best for the transforming team. Interventions for transforming to team-based care have grown and expanded, based on validated transformational steps, starting with the National Demonstration Project, NDP, launched in 2006. Proving the three foundational elements of successful transformation to team-based care are leadership, communication, and teamwork. They can all be challenging to identify and control, but using behavior change theory, and proven change management, the transformation to team-based care delivery models can be successful and result in the desired, sustainable, and proved care delivery models that positively impact quality outcomes and better healthcare costs. Transformation to a collaborative team-based care leadership style impacts the whole team. The old, traditional, top-down, autocratic approach exhausts the leadership, while failing to engage the rest of the team members. Transformation to team based care will only work if everyone becomes an active part of the change. It is important to prioritize sufficient time and effort to ensure successful transformation into team-based care. Transformation to a collaborative team-based care leadership style impacts the whole team. Transforming the culture towards team-based care requires the coordination and integration of every functional area of the practice, including the patient. Team-based care's success and sustainability depends on the key elements, communication, leadership, informatics, and teamwork. Team-based care needs to nourish a rewarding, adaptive, team based practice culture, and become a learning system culture where teamwork thrives. Refer to component 18, unit 10 for more information on change management. Simultaneously accessible and adequately coordinated care delivery demands transformation to team-based care, where the patient is included as part of the high-functioning team. Team members are enabled with health information technology systems to care, coordinate, manage, monitor, and track teamwork tied to the agreed upon and assigned team roles, responsibilities and accountabilities. Team based care task designation is by skill set, with everyone working at the top of their skill set, licensure, or special training ability. Redistributing workload gains efficiencies and work experience satisfaction. Physicians delegate to other team members the tasks and functions that do not require medical training, in order for the physicians to work at the top of his or her licensure. Continuous quality improvement using systems engineering principles produces leaner team-based workflows and fosters a strong, focused, efficient team. Many healthcare teams, once frustrated by performing reactive care, have moved to better functioning proactive care. Proactive care implements population health management processes, allowing care to be planned, collaboratively accomplished with the patient and family when appropriate. Data analytics support care decisions, wellness promotions, disease prevention, early detection, and chronic disease management. Population health management includes providing care proactively to the whole person over time in a setting with efficient health information technology and robust registries for managing and improving chronic disease outcomes, screening and prevention measures, and best practice tools for patient engagement and activation through collaborative self management support. Refer to component 21 for more information on population health Establishing the transformation to a collaborative team-based care rollout strategy includes developing a roadmap or plan to designate phases for baseline assessment and reassessment milestones, where transformation gap analyses can serve to identify precisely where the transformation leadership may need to redirect communication, teamwork, and informatics to meet transformational goals. Transformation can be accomplished in phases over time, with or without assistance from one of the many excellent national team-based care transformation professional consultation organizations. However, assigning practice facilitation coaches is essential for achieving success through advancing teams through a standardized approach and curriculum, incorporating behavior change theory and organizational development methods and best practices. The Department of Health and Human Services, HHS, has funded transformation to team-based care demonstrations, and has provided grant opportunities resulting in studies that have created, validated, and provided transformation road maps, free tools and resources through federally funded organizations, and groups such as the Agency for Healthcare Research and Quality, AHRQ, and others. Standards and criteria used in the recognition of team-based care have been developed and are a part of patients centered medical home recognition programs through the National Committee for Quality Assurance, NCQA, the Joint Commission, Utilization Review Accreditation Commission, URAC, and others. Patients, their families, and other partners in care are respected as essential members of the health care team, helping to ensure quality and safety. Family members provide support, comfort, and important information during ambulatory care experiences. A hospital stay in critical care, medical, surgical and specialty units. In an emergency room visit, and in the transition to home and community care. This concludes Lecture b, Transformation Planning of unit two, Team-based Approach to Patient Care. In summary, this lecture included three foundational elements of successful transformation to team-based care are leadership, communication, and teamwork. Requirements for creating culture change. Going from reactive to proactive care. And creating a team-based rollout strategy for intervention.
