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The Team Will See You Now...What Team?

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Have you heard that soon most primary care in the U.S. will be delivered by teams?

Yep. Team-based care is one of the characteristics of the patient-centered medical home, a way of organizing the care of patients that allows primary care clinicians to see more patients in a day while at the same time delivering better care. This move toward team-based care started long before health care reform and was embedded deeply into the Affordable Care Act through its support for patient-centered medical homes and Accountable Care Organizations. It has been endorsed by the professional organizations of our primary care clinicians. There is a lot of activity directed toward making this the way most of us receive our regular health care.

What does this mean for us?

It’s not clear. The growing literature on team care focuses mostly on the skills that primary care clinicians, professionals and office staff must learn and the changes they must make to deliver care as a team: how they should be trained, how the work-flow is organized, how the group is led, how to build cohesiveness and trust within teams, how team members should communicate, etc.

How team care will affect us directly is sparsely described, but when it is, it is common to find promises that teams will coordinate our care among different settings (different specialists and hospitals, for example), that teams will pay more attention to helping us learning how to care for ourselves, and that we will have greater access to team members who can answer questions and help us solve minor problems. In a few papers, reference is made to “patients and families being members of the team.”

Recently, I was asked to make some remarks about team care at a conference. Now, I have heard from a number of people over the years about their experience of being cared for by an oncology or cardiology team during cancer treatment or after a heart attack, for example, and they thought it was great being able to call the nurse, for example, and get quick, useful help. But I hadn’t heard anything about people’s experience with primary care teams.

So I asked 10 people (regular ones, not health care experts) I encountered over the course of a couple weeks what they thought about the idea that “your regular health care would be delivered and coordinated by a team of people – your doctor and nurse and maybe a pharmacist and social worker and others, not just your doctor” meant for them. (Tiny sample, not representative, I know).

Their comments clustered around three themes:

1) People were concerned that a team would make getting care less personal:

“Team care doesn’t sound good. I just want my doctor to take care of me. I think this team care thing would get in the way of that.”

“What, now they want me to know all these other doctors and nurses and aides and other professionals and to figure out that I have to call this one for this question and that one for that question? It’s bad enough as it is. Sounds like the management consultants are running the show.”

2) People were puzzled about what difference being cared for by a team would make.

“I’m a member of Kaiser Mid-Atlantic so I suppose I’m treated by a team. You’d think they would look at me as a whole person but I still go off to see the foot doctor and the hand doctor and the heart doctor and the only thing they share is my electronic health record.”

“You know, they might have team care already for all I know. No one wears a name tag or tells me who they are or what their job is. I just shuffle around wherever they tell me.”

3) I asked them whether they thought they and their spouse or someone else they chose should be members of the team.

“I don’t think I should be a member of the team, but I should have the final say about my care.”

“Are you kidding? I don’t know what they know and all those different specialists and nurses talking about my problem? Nah. They have to organize it for me.”

I too am puzzled about what team care means for us. When – and why – as a patient, do I need team care and what do I need to know about it?

Here are a few questions I – and many of my fellow patients – would like answers to:

First and foremost: Will I do better if my care is delivered by a team? Will my chance of having a better outcome improve? This is what I value. This is the bottom line.

And then, will my experience of my care be better – safer, more effective – if delivered by a team? For example:

  • Will I have less contact with my trusted physician or will team care enhance our relationship?
  • Will team care afford me greater opportunities to understand my health problems and discuss my choices about treatment?
  • Will team care mean there are more “rules” for me to follow to get help from my doctor? More gatekeepers?
  • Will team care make it easier for me to get answers to my questions/prescription refills/appointments?
  • Will my team coordinate my care so I don’t have to?

I don’t know the answer to these questions, but I can see that team care has the potential to affect positively or negatively both the outcomes of our care and our experience of it.

If shifting to team care means that our care will improve, why not tell us how. Explain (again and again) what we should expect from our team and help us understand how to take full advantage of the change. This is one way for teams to hold themselves accountable for their promises: tell us your goals and then ask us if you’re meeting them.

And should we consider ourselves members of the team? Try asking for our preference.

More information on this topic with The Center for Advancing Health's “Supporting Patient Engagement in the Primary Care Medical Home

More Blog Posts by Jessie Gruman

author bio

Jessie C. Gruman, PhD, was founder and president of the Center for Advancing Health from 1992 until her death in July 2014. Her experiences as a patient — having been diagnosed with five life-threatening illnesses — informed her perspective as an author, advocate and lead contributor to the Prepared Patient Blog. Her book, AfterShock, helps patients and caregivers navigate their way through the health care system following a serious or life-threatening diagnosis. The free app, AfterShock: Facing a Serious Diagnosis, offers a pocket guide based on the book. | More about Jessie Gruman


Tags for this article:
Medical/Hospital Practice   Patient Engagement   Health Care Access   Jessie Gruman   Organize your Health Care   Inside Healthcare  


Comments on this post
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maggie says
February 27, 2013 at 7:53 PM

I'm all for the team approach--easier access, etc--but it absolutely scares me when none of the assorted members of "the Team" bother to look at the electronic chart entries of the other members, or if their paper charts aren't complete. As in, "hmmm. What was this test for, and did anybody tell you the results?" or when lack of communication or disagreement with one another is obvious. If I felt well enough to manage their end of my care, I wouldn't be there in the first place.

Chris Langston says
March 7, 2013 at 12:18 AM

Thanks Jessie - this is an important issue. We health reformers are so gung-ho about teams we don't think about how regular people might see this "innovation." And bad teams and bad team work certainly have given people who need care a reason to be skeptical.

Still care is already delivered by "teams" - that is people who are SUPPOSED to be working together with common purpose, differentiated roles, and methods of coordinating their efforts. (They just have often missed the part about purpose, roles, and coordinationon.)

We can only meet the needs of the population with more and better team work, so we'd better figure out how to do it right and how to get people to give it a chance.

Jake Fleming says
March 18, 2013 at 11:06 AM

Nice post.

Tom Bodenheimer says
March 18, 2013 at 2:26 PM

A couple of years ago I noticed that the Veterans Administration health care system’s primary care redesign effort had two major goals: patient-centered care and team-based care. I asked myself, Are these goals compatible or conflicting? Do patients want teams? I have been advocating for primary care teams for quite some time. But that haunting question -- do patients, accustomed to physician care, want teams? – keeps me up at night. Is team-based primary care the right way to go?

For the next few decades, perhaps forever, the US will not have enough adult primary care physicians to meet the growing demand. We need teams to add primary care capacity. But is this the best solution or a second-best option arising from a physician shortage?

I have come to believe that if we do it right, people needing primary care could enthusiastically embrace teams. Jessie Gruman’s sample of 10 people provides a lot of wisdom and we need to listen to their voices. Some more wisdom comes from a Blue Shield of California Foundation 2012 telephone survey of poor and near-poor Californians. For 80% of respondents, it was important to have someone in your health care facility “who knows you pretty well.” 60% said there was not such a person where they receive care. 67% said they do not have a regular health care team. Of those reporting a regular team, 94% liked having the team. Of those without a team, 81% said they would be willing to be seen by a team even if it meant seeing the doctor less often. These results suggest that having a personal relationship with someone is extremely important even if that someone is not a physician.

Perhaps a problem with most primary care teams is that they are too large and patients may not have one person “who knows you pretty well.” To address this issue, high-performing practices generally organize their teams around teamlets. A teamlet is usually a two-person dyad, often clinician (MD, NP or PA) and medical assistant (in some cases RN or LVN). This stable teamlet works together every day or as close to every day as scheduling allows. A larger team -- perhaps including RN, social worker, pharmacist, and behaviorist – supports 3 teamlets. The teamlet – not the lone clinician – assumes responsibility for the health of its panel of patients. Patients are not asked to share their trust in the physician with 5 or 6 other people, but with one other person. Ideally, both teamlet partners “know you pretty well.” Some practices give patients friendly business cards with the names of their clinician and medical assistant. In these practices, many patients know, trust, and rely on both teamlet members. We need research to find out whether people seeking primary care can truly trust a team, and whether they prefer teamlets or larger teams.

Teamlets are a throwback to the old days when a GP and nurse worked together perhaps for 20 or 30 years. They trusted each other and patients trusted both of them – sometimes the RN more than the physician. If we can transport the teamlet from 60 years ago and organize our more complex primary care practices around such small teams, perhaps team-based care can become truly patient centered.