The role of team-based care on the path to health care transformation

Population Health and Team-Based Care

The term population health management is in wide use but the definitions of it range just as broadly.  In the 2014 report by global IT research firm, IDC Health Insights, the population health management market is defined as, “the people, processes, data, and information technology to improve the health of both individuals and communities.”[1]

Technologists and clinicians are working together and making great strides in developing business intelligence tools to identify health risks, software applications to coordinate the work of provider-led care teams, and communication tools to grant patients access to their protected healthcare data.

According to the Institute for Healthcare Improvement (IHI), such “team-based care” will the norm within 10 years. This is due, in large part from the new models of care and reimbursement and growing provider adoption of care teams as a way to improve practice efficiency, and to improve provider and patient satisfaction. [2]

Some are concerned, however, that healthcare delivery organizations put at risk the trusted doctor-patient relationship when nurse practitioners, physician assistants and clinical pharmacists divide responsibilities once handled by the doctor in charge. Still others are equally concerned that patients will not have an active voice in their care plans, given the reliance care teams have on information technology and the relatively low investment emphasis placed on patient health IT to date.[3]

The purpose of this paper is to explore the relationship between new and emerging models of care delivery and the potential risks and benefits to patients who are striving to become more active healthcare consumers. The role of the care team as an efficient and effective model of care delivery will be discussed.

Healthcare is in Flux

FACT: Health care in the United States is in a constant state of flux. Depending Regardless of which side of the transformation divide you are on – fee for service (FFS) or value based reimbursement (VBR) - there are a myriad of forces at work that have put healthcare system in flux. In cooperation with National Public Radio, Kaiser Health News reported that there are seven factors driving up healthcare costs in America.

  • We pay our doctors, hospitals and other medical providers in ways that reward doing more, rather than being efficient.
  • We’re growing older, sicker and fatter.
  • We want new drugs, technologies, services and procedures.
  • We get tax breaks on buying health insurance — and the cost to patients of seeking care is often low.
  • We don’t have enough information to make decisions on which medical care is best for us.
  • Our hospitals and other providers are increasingly gaining market share and are better able to demand higher prices.
  • We have supply and demand problems, and legal issues that complicate efforts to slow spending.

FICTION. Ignoring the changes of this change state is an option for improved patient care and physician satisfaction.  As the healthcare landscape evolves, primary care facilities across the country are reaching for varied and unique ways to improve not only patient care, but also the way in which they deliver it to a large number of potential patients.

How Primary Care is Changing

Primary care, in an ideal situation, is seen as the foundation of a well-functioning health care system.  However due to a trending national focus over the past decade towards high revenue specialty care, primary care has witnessed consistently decreasing numbers of medical students entering into it.  The lack of recognition of primary care has led to a dearth of providers and the field as a whole has suffered.

How does one begin to undergo the transformative process for primary care? One initial step is to focus on the way primary care practices manage the patients within their care environment. Historically, patients have been seen by their physician, with the assistance of a nurse (which could be a registered nurse (RN), licensed vocational nurse (LVN) or certified medical assistant (CMA)).  With payment reform and the demand for quality measures, the typical care format will no longer be sufficient.

The typical 15-minute all-encompassing visit will no longer be adequate for quality care.  This has led to the concept of care teams and patient centered medical home (PCMH).  In this expanded universe of health care, team members are asked to work to the highest level of their training and licensure in a collaborative manner. Multiple members perform discrete but complementary tasks; in coordinating their interactions at various touch points to improve the overall well-being of the patent.

Information Technology as an Enabler

In this new world, new players are explaining the definition of the traditional health care team.  Now Pharmacist, Registered Dieticians, Physical Therapist, Mental Health Professionals and Techs – pharmacy, lab or radiology – all have a role to play in ensuring patients transition from one area of the health system to another. So, how does the primary care physician stay connected in this new role as quarterback of the care team? Technology has the ability to do the job in a multitude of ways.  At the most basic level, technology today allows us to communicate faster, more efficiently and in creative ways. 

This same technology can and is allowing care teams to interact with patients in unique ways, such as through social media.  As patients and care teams increase their interactions, care teams themselves will be able to interact in unique ways within a system. Whether it is Post-It notes or flags within a care coordination platform, , or through virtual “team huddles” that do not require physical presence, technology is enhancing and hopefully making more efficient the way in which teams interact and share information.

Health information technology is also able to create efficiencies of scale in helping organizations and even small practices understand exactly what types of patients they are caring for, and more importantly, where gaps in care exist.   The hope is that over time, as volume based care cedes way to quality care, that the cost of risk will be not only shared, but covered by utilizing new and exciting technologies.

Are there challenges in this new world of technology and healthcare? As the 2014 Ebola outbreak in Dallas showed us, technology cannot solve all that ails our healthcare system.  Technology can facilitate the conversation, but should never take the place of communication.  The proverbial technology Tower of Babel exists today, which makes connecting patients across disparate networks challenging.  A patient going from an Patient Centered Medical Home with one EHR to a Federally Qualified Health Center for physical therapy, and then across the street to a laboratory with a third system, may find themselves literally tongue-tied and worn out, not to mention clinically unintegrated.  Interoperability will be the next great challenge in this landscape of primary care transformation. 

Once upon a time, the debate whether patient care is enhanced through health IT raged in the journals. Recent data ( ) shows the benefits for patients IT brings to the table.  A primary advantage of HIT is the ability to take disparate information to one place, and ultimately consolidate otherwise fragmented information into one team for the best case analysis for patient care. Care teams, depending on where you practice, are either the standard of care, or the direction of future care, and must become the established practice and not the outlier for improvment. The technology exists and needs to be utilized to realize the potential for improving patient care; experience AND outcomes.


[1] IDC Health Insights Evaluates U.S. Population Health Management in New IDC MarketScape.

[2] “Team-Based Care: Saving Time and Improving Efficiency,” Kevin D. Hopkins, MD, and Christine A. Sinsky, MD. Family Practice Management. 2014 Nov-Dec;21(6):23-29.

[3] Report: Health Care Industry Lags in Use of Patient Engagement Tools,, February 12, 2015.

patient-centered care teams, patient engagement, patient-centered medical home