Defining the Patient Centered Care Team: Doing More with More

From the Patient Engagement with Patient-Centered Care Teams Task Force

Care teams are replacing the traditional “assembly line” approach to healthcare.   These newer models, which include Teamlets [1]  and Family Team Care[2] require not only changes in resources but changes in approach.   Patient Centered Care Team models call for multi-disciplinary skill sets that broaden the expertise to determine optimal treatment plans for patients.  But bringing more cooks to the soup pot has traditionally raised red organizational flags for higher cost, group thing, and extended time in meetings.   Aren’t we striving to do more with less?   These cautions have merit, but to make the Patient-Centered Care Team an effective means to health care improvement, information sharing and compression of timing and logistics can overcome “business as usual.”  Team care means doing “more with more” to improve outcomes and reduce costs[3].

Team based care models have a few recurring themes:

  • Teams are not static, but roles are

Care teams need to be fluid enough to involve experts that can help evolve more thorough care plans.  Complex medical cases teams may involve several specialists, while other patients may require social and welfare support to improve care.  It’s conceivable that some care teams wouldn’t involve a physician at all! 

  • Teams can extend beyond single organizations

Small, community providers often do not have staff and expertise to accommodate all patient needs, especially those with complex clinical and social needs.  These providers will need to work more closely with community providers to create formal relationships that establish “virtual” care teams as needed.    

  • PCP as QB

While physicians, especially small primary care providers, take on broad responsibilities for patient  care, team models emphasize the physician as the orchestrator of the care plan, with nurses and extenders providing more services directly to patients[4].    The goal here is to create optimal use of expertise and skills.

  • Patients are managed within panels, but still with attention to specific cases

Population health strategies provide an excellent stepping off point to structure care teams.   The ability to understand patient panels by condition and need will enable the care teams to organize activities efficiently. 

  • Matrixed accountability of organizational responsibilities and patients

Within patient panels, team members need to understand not only their organizational duties to provide care, but also the ability to see each patient in their broadest context.   This context is general found within the patient care plan that is established through team input and developed over time.

  • Communication and information sharing  

Teams cannot function without effective communication.  Team care models require more than just information aggregation or availability.  Patient care information needs to be presented in “ready to use” views and not require caregivers to search and retrieve information in parcels, or wait for updates to get the most current patient information. 

To effectively support care teams, technologies will need to further develop capabilities in the following areas:

  1. Interfaced for data, if not interoperable. If a technology operates in isolation, without AT MINIMUM, interface for data sharing, it will fast approach obsolescence as team care expands.
  2. Views meaningful to the user. The more clicks that it takes a user to get to useful information, the faster the application will be abandoned.  This is human nature and software will not overcome that.
  3. Real time or close to it. As data interchange and HIE improve, real time information for care teams will be a boon to developing care plans more effectively.
  4. Supports newer more efficient processes. There are literally thousands (perhaps more) software that can do good things for patients and providers, but if it requires additional work, or is conceived in the existing state of work, the entire team care process breaks down.
  5. Multimodal communication suited to receiver preferences. Information can be spread securely and electronically to multiple endpoints.  This is a fortunate fact of the world we live in.  Supportive technologies will take advantage of this to improve care.


[1] The Teamlet Model of Primary Care

[2] A New Approach to Making Your Doctor-Nurse Team More Productive

[4] A Quarterback's View of Care Coordination


Our next post will explore the specific areas where technologies will require enhanced capabilities to more adequately support care teams.  

Authors: Karen Mingain PMP, CHTS-IM, Director, HealthNET Systems
James Rose, Managing Director, PhaseSpace