Intuitively, team-based care models make a whole lot of sense: the primary care physician (PCP) should be the “quarterback” of the patient’s care while a supporting team handles the execution of the plan. Pharmacists, nurses, social workers, care managers and a host of others can be engaged so that those critical details of a course of treatment are delegated in such a way that each player is “working at the top of his/her license” and, it is hoped, care is delivered in a more efficient and patient-centric way that addresses all the needs of the patient, even the non-clinical factors that many have identified can disproportionately impact health outcomes.

A team based approach can take many forms, but the core of the philosophy can be organized around principles outlined by the Institute of Medicine in 2012:

  • Shared Goals between both patient and the care team
  • Clear Roles and expectations for all stakeholders
  • Mutual Trust between all members of the team
  • Effective Communication between all stakeholders and across all care settings
  • Measurable Processes and Outcomes to track and improve performance

Over the next few days, we’ll dive into these principles and discuss how can technology advance these principles and what else is necessary for success.

Shared Goals

As a recent article suggests, patients and care teams may not always have the same goals. One quote from the article illustrates this: “Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function.” When the patient and provider are not aligned, a whole variety of unintended consequences like difficult, expensive and risky procedures that may not contribute to the patient’s life goals are possible. On the patient side, a lack of adherence, or a failure to comply with provider instructions can result.

While it is key to have these critical conversations between PCP and patient, it is just as important to ensure that the outcomes of these conversations are documented so they can guide all players on the care team. A seemingly simple solution is to use some form of “Care Management” software to allow the care team to collaborate both in real time and asynchronously, especially as the patient moves between a variety of settings.

But software alone is insufficient. Since most medical organizations are not yet completely integrated across various settings and the notorious lack of interoperability between different EMRs makes information sharing extremely difficult, this type of linked communication becomes both an organizational as well as a technological challenge. Executing on data warehousing and information exchange is one part. Understanding how the care teams “do their business,” how they and patients wish to communicate and the pathways to care taken by patients is another, equally important part.

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