Team-based Approach to Population Health Management: The Promise for a Better Healthcare

Where does the healthcare stand today? Are we way ahead than what people think or do we still have to walk a lot more?

Anybody who has seen the US healthcare closely would have encountered these questions at some point in their journeys. And who could be better poised to answer these questions than the ones who are a leader in the domain?

Last Tuesday’s morning began with a highly informative and grand webinar where Dr. David Nash, Founding Dean of Jefferson College of Population Health, Dr. Paul Grundy, the ‘Godfather’ of the Patient-Centered Medical Homes, and Dr. David Nace, CMO at Innovaccer, shared some really thoughtful insights on the value of team-based approach in healthcare.

Airlines and healthcare- A comparison never heard before!

One analogy that suits the best to describe the present condition of healthcare is with the airline industry. Some thirty years ago, when the airline industry was very pilot-centric, the accident rates were very high. However, they had adopted a team-based approach and made decisions made on the basis of the data available and insights from the other members of the team.

Although healthcare is still in early stages of adopting AI and digital technologies, it is already making significant strides. What we need to do to bring healthcare ahead of other industries is to change the culture of communication to be more organized, regimented, timely, and collaborative.

“It is time to move from a physician-centric healthcare to a team-centric healthcare.”

What is a team-based care and why should we care about it?

‘More than one person for providing the care’ - the one line definition that encompasses every detail which could be covered in understanding the team-based care.

Team-based care is when every member of the care community work together and top of their licensure from the provider and patient-end, including administration staff and family members, to provide the care the patient deserves. With every member involved, we can share responsibilities, enhance patient access, provide better patient experience, and whatnot.

And why am I so sure of this?

According to a survey conducted by the Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost, organizations that adopted the team-based model had 23% lesser ED visits, 10.6% lesser hospital admissions, and 7% fewer primary care encounters, against the ones which didn’t adopt the technique.

Who is the most important in a team— Can this ever be identified?

In a team, no member is more important than other. Every stakeholder has some great value to add to the team. It was quite interesting to notice the audience’s response to the webinar poll. In the poll, they were asked which team members are the most important to be included in the team.

According to the response, every members shared nearly equal percentage of the importance. Such results clearly state that involvement of every stakeholder is critical for healthcare to progress.

Why is adopting the team-based approach such a hard nut to crack?

Earlier we used to build cathedrals with a master builder who had a plan in his head. However, nowadays, the approach to build the skyscrapers is quite different. We need engineers, designers, architect, and even, data.

The team-based approach in healthcare is pretty similar. It cannot rely on only one aspect of care delivery. Every piece has to be fit in its right place. However, the major challenges hindering the way include:

• Finding the right composition for the team
• Building the leadership to drive cultural change
• Driving better communication across the team
• Promoting training for teamwork
• Choosing the right technology support for the team

Based on the poll, nearly one-fourth of the audience considered integrating care coordination into the team is among the most challenging task in implementing team-based care, followed by addressing the social determinants of care and engaging the patient into the process.

A 5-step guide to a holistic team-based approach to healthcare

I cannot focus more on the importance of every stakeholder in driving value to healthcare. In their webinar, the triad proposed an effective 5-step guide to building strong teams and delivering proper care.

• Engaging a transformation team

Bringing together the right team with multi-disciplinary functions is the first step towards building the right team-based healthcare space. In healthcare, every player has something crucial to contribute, even patients, and to ensure that they all remain connected and actively participate in shared decision-making is very important. In terms of primary care practice, teams can be categorized at three levels to streamline the workflow:

• Core Team: A defined patient panel and includes provider, a clinical assistant such as a medical assistant, perhaps an nurse, health coach, among others.
• Extended Team: Behavioral health consultant, social worker, care coordinator, et al. (shared resources).
• Affiliated Staff: Part of the care team through formal links with outside organizations.

• Building the leadership that drives the cultural change

Once people are connected, they can learn workflow and other processes to work together instead of working as an independent member. This transition is majorly driven by the leadership. In order to ensure that every member remains connected, it is crucial that their leaders remain connected and engaged. Together, they can support and drive the cultural change that is required to build a smarter staff network.

• Strategic redistribution of work

The formed teams need to clearly identify and define their goals and functions. With properly aligned functions, they can strategically distribute the responsibilities to maximize the efficiency of every team member to create an ecosystem of shared responsibilities. The main theme of a team-based healthcare should be to move from ‘my patient’ to ‘our patient.’

• Enhancing communication, connectivity, and decision support

Imagine a world where nobody is documenting in the EHRs rather they have an Alexa-typeenvironment where healthcare members are talking and is automatically recorded. That should be the future.

To ensure that every member of the team is optimized, it is necessary that they remain connected in near or real time, are empowered with trustworthy data, and supported with actionable insights. Patients should know what to expect and feel comfortable with the team. They (and their designated caregivers) can become powerful members of the team.

• Optimizing the care team

Every member has a unique role to play and care processes can only be streamlined when they carry forward with their respective responsibilities. Technology plays a very important role in optimizing the care teams and managing the care-delivery processes by:

• Streamlining processes across the care teams
• Leveraging automation and decision-making processes to streamline the tasks
• Engaging every member of the care team including the patients

The road ahead

Team-based healthcare is not just an approach but a promise to a better healthcare. From engaging patients in their care journey to involving every stakeholder in shared decision-making process, healthcare teams can deliver better outcomes. We are moving towards a new breed of health professionals - ones that value and thrive through teamwork, have strong patient engagement skills, and receive incentives through achieving better outcomes. And no time can be better than now to move from a discrete healthcare to connected team-driven healthcare!

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This blog has originally been authored by Abhinav Shashank.