How to Capitalize on a Team Based Approach in Primary Care

In the article From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider, the authors highlight the effects of provider burnout on population health. It was noted that burnout leads to poor patient outcomes and when left unchecked, providers leave the profession. Replacing primary care providers is an expensive and difficult task. There are resources such as coaching programs to assist healthcare providers to deal with the burnout they may be experiencing. However, the healthiest and most economical approach is to avoid burnout. The research highlights team based care as one of the mechanisms to avoid burnout.

In 2010, the IOM report on the Future of Nursing, one of the recommendations noted was to ensure that nurses are working to the top of license and education. The Center for Medicare and Medicaid Services (CMS) began embracing the concept of a team based approach to care in 2011 when Annual Wellness Visits were introduced. They further expanded the use of team based care in 2013 and in 2015 with the implementation of Transition Care Management (TCM) and Chronic Care Management (CCM). Their latest addition to approved services using the team based approach was introduced in 2016 with Advance Care Planning (ACP). However, not all primary care practices are taking advantage of this practical and profitable approach to care.

Using a team based approach is more than just acting as a team; it incorporates the skills of everyone in the practice to function at the top of their license and education. The practice can and should bill for the services that are provided to patients using this approach. In the primary care setting in particular, a care coordination program that encompasses CCM/TCM, AWV, and ACP and using the team based approach to care benefits the patients and adds to the bottom line of the practice. Implementing a team based approach requires providers, nurses, and other clinical staff to incorporate the following principles into the practice:

    • Establishment of shared goals
    • Understanding of clear roles
    • Development of mutual trust
    • Utilization of Effective communication
    • Measurement of processes and outcomes

At HealthTechS3, we implement our care coordination program using the team based approach. To learn more about using team based care in the annual wellness visit process, please watch our webinar: Data Driven Approach to Medicare Wellness: Good for the Patient, Good for the Practice.

If you would like more information, please contact.

Author: Faith M Jones, MSN, RN, NEA-BC, Director of Care Coordination and Lean Consulting HealthtechS3