Providers work to create a culture of team-based care

Dr. David Williams had to make a lot of adjustments when the UnityPoint Health clinic he practiced at in Des Moines, Iowa, transitioned to a patient-centered medical home model in 2015.

Williams, a pediatrician and CEO of UnityPoint Clinic, was used to managing his patients largely on his own. But it was exhausting work. He could spend up to two hours after the clinic closed calling parents back because his day was so jam-packed with visits.

That all changed under the patient-centered medical home model. Williams has a team of advanced practitioners and care coordinators to help him manage patients. This has freed up his time to make follow-up calls during the workday and see patients faster if necessary.

But it also forced Williams to realize that he had lost control. Some parents now prefer their child be seen by an advanced practitioner rather than Williams in part because a nurse practitioner likely can see patients sooner and spend more time with them.

"That's kind of an ego blow," he admitted.

But Williams said he's comforted by the fact that because of the changes, his patients are able to receive care when they need it and it's much more comprehensive. "In the primary-care world, people have been running hard on a treadmill for years and years. The thought that more can be done for patients, and more efficiently, overwhelmed the negativity," he said.

Still, it's not a given that doctors in general are ready to accept a diminished role, even though it's necessary for team-based care to work. Physicians need to embrace the fact that they no longer run the show, said Dr. Paul Di Capua, regional medical officer for CareMore in Connecticut.

Di Capua works with a team of case managers, social workers, nurses and nurse practitioners to treat complex patients, largely in their homes.

CareMore is an integrated health plan and delivery system operated by Anthem, so in general it has more direct incentives than delivery systems to adopt team-based care.

Traditionally, doctors are trained to work in a care model in which their medical decisions determine the priorities of their co-workers. But Di Capua argues that in a true team-based model, his position as a doctor is no more important than the social worker or care coordinator. Everyone has a unique skill set they bring to the table for the patient. And sometimes a solution that will help a patient isn't clinical but personal, like making sure the patient has a comfortable bed.

Although Di Capua said he finds the team-based culture "rewarding," he understands why it "wouldn't sit well with some doctors who are more classically trained."

"Team-based care requires a kind of humility on the part of doctors and nurse practitioners," he said. "We are trained to make medical decisions, and the system rotates around us. In team-based care, it doesn't work like that. It's a web of people working together."

It's not necessarily the clinicians' fault that they may not be ready to jump into team-based care when asked to do so. Clinicians—especially doctors—are still too often educated and trained in silos, so when organizations, particularly clinics, want to implement a collaborative working environment, cultural stigmas can stand in the way.

While some medical schools are revamping their curriculums to remove those stigmas or are even starting from scratch—as is the Kaiser Permanente School of Medicine, slated to open next year in Pasadena, Calif.—team-based learning still isn't a common practice. Medical schools can start to perpetuate the culture needed to embrace teamwork, said Dr. James Merlino, president and chief medical officer of Press Ganey's strategic consulting division.

Experts cited other reasons why team-based care isn't as widely used as it could be. One barrier to implementation is the fee-for-service payment structure, said Dr. Kirsten Meisinger, a faculty member at the Institute for Healthcare Improvement and regional medical director at the Cambridge (Mass.) Health Alliance.

Team-based care optimizes support staff such as care coordinators to keep patients healthy and out of clinics or hospitals, but a fee-for-service approach wouldn't typically reimburse for those services. "It's really hard to make changes when a tiny portion of your funding is value-based," she said.

Despite such hurdles, Meisinger said it's still in the best interest of organizations to work toward a team-based culture because value-based payment is only expected to accelerate.

"You should be paying attention," she said.

A critical component in creating a team-based culture is making sure staff members understand—and support—the reasons behind changes, said Stephanie Baker, managing director and coach leader at the Studer Group. "In the absence of clearly understanding why, people are afraid, or they think they know better," she said.

For Mount Sinai Health System in New York City, creating care teams was eased by the fact that physicians understood why they were trying to integrate behavioral health specialists into their clinics. Primary-care doctors often saw patients with behavioral health needs in their clinics and felt hopeless to treat them since they had limited resources available.

Some physicians also just simply didn't feel comfortable discussing mental health issues.

"They all recognized the need to address behavioral health services. The interest and desire were there," said Dr. Sabina Lim, chief of strategy for behavioral health at Mount Sinai.

Support from primary-care providers was a key reason why the model was adopted across so many clinics, said Dr. Lauren Peccoralo, assistant professor of medicine and director of primary care under the model.

As for the mental health specialists, Mount Sinai officials specifically targeted those who they believed would work well in teams, Lim said. The general model, which is currently in practice at 18 Mount Sinai clinics, involves primary-care physicians referring patients with behavioral health needs to on-site social workers. The doctors and social workers then share notes about patients' progress in-person, through the EHR or during weekly meetings. It's easy for the physicians and social workers to build a comfortable relationship because they work together every day in the same clinic, Lim said.

The front-line staff of each clinic also have the flexibility to alter the model to best suit their needs, which Lim said was also essential to gain their support. "It was really important for the people who were going to run it and do it every day to work out all the details," she said.

When individuals feel they have ownership over the process, they are more likely to embrace it, Baker added.

"They might not set the metrics and the standards might be required, but they can develop how they are going to do it," she said. "They are going to be more invested and they are more likely to be highly reliable."