Care Coordination and Interoperable Health IT Systems Unit

Care Coordination and Interoperable Health IT Systems Unit 2: Team-based Approach to Patient Care Lecture a – Multidisciplinary Care Planning This material (Comp 22 Unit 2) was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90 WT 0006. This work is licensed under the Creative Commons Attribution-Non. Commercial-Share. Alike 4. 0 International License. To view a copy of this license, visit http: //creativecommons. org/licenses/by-nc-sa/4. 0/.

Team-based Approach to Patient Care Learning Objectives • Objective 1: Identify best-practice types of team-based interventions (Lecture a) • Objective 2: Describe key elements for transforming to team-based care (Lecture a) • Objective 3: Plan for transformation to teambased care (Lecture b) • Objective 4: Identify evidence-based clinical practice guidelines resources (Lecture c) 2

What is Team-based Care Coordination? • At least two health providers • Collaboratively with patients and their caregivers • To accomplish shared goals • To achieve coordinated, high-quality care Naylor MD, Coburn KD, Kurtzman ET, et al. (2010) 3

Overview of Team-based Care Coordination • Collaborative team partnership relationships • Ensure defined, structured processes • Encourage continuous quality improvement and best practice tools used for collaboration, coordination, and communication 4

Team-based Care Coordination: Why? • Develop relationships around the care of our patients • Helps transition between the entities of the health care systems – Transfers critical information at the point and time in care when physicians need it most 5

Team-based Care Coordination: When? • Transitions over time as information transfers and / or responsibility shifts • Between episodes of care (initial visit and follow up visit) • Across lifespan (pediatric developmental stages, women’s changing reproductive cycle, geriatric care needs) • Across trajectory of illness and changing levels of coordination need 6

Team-based Care Coordination: Who? • Amongst members of one care team – Reception to Nurse to Physician • Between patient care teams • Between patients and informal caregivers and professional caregivers • Across settings (primary care to specialty care, inpatient, emergency department) • Between health care organizations 7

Quadruple Aim of Team-based Care 1. Improve the individual patient health experience 2. Improve population outcomes 3. Lower costs 4. Improve health care clinicians’ experience 8

Team-based Care: A Preferred Model • Establishes collaborative roles, responsibilities, and accountabilities • Measures and improves outcomes with data-driven measurement of interventions • Reduces costs in care 9

Examples of Team-based Care Models • Advanced primary care models • Patient-centered medical home models • Accountable care models • Community care models • Shared savings models • Bundled reimbursement models • Etc. 10

Example: Team-based Patient. Centered Medical Home (PCMH) Model of Care • Highly desired • Standardizes learning and technology systems • Drives evidence-based, patient-centric interventions 11

A Shift from Tradition • Traditional physician’s practice: – Care delivery fractured – Composed of silos – No understanding of entire office workflow or how one’s role interacts with others’ roles 12

Benefits of a Team Approach • Brings an understanding of all practice operations • Teams are more involved at every level of implementation • Each member still has specific roles and shares information • A team member can stand in for colleagues in any situation 13

Patient’s Role • Patient and family are active members in their care • Share in decision-making and learn about self-care management 14

Multidisciplinary Care Planning • In team-based care roles: – Responsibility and accountability is spread across the team – Referring physician is ultimately responsible for the patient’s care by the whole team 15

Multidisciplinary Care Planning (Cont’d – 1) • Multidisciplinary collaborative team members combine their aggregate experience, knowledge, intellect, and expert skills • Teams optimize coordination and delivery of comprehensive healthcare • Team-based care aims to provide the best possible outcome for the whole-person, physical, and psycho-social needs of a patient and family when appropriate 16

Planning for Complexity • Team’s roles may expand across multiple care settings • Collaborative teams address complex special needs • Teams coordinates for the best possible outcomes 17

Multidisciplinary Team Members Related to Care Coordination • Hospitals and integrated systems clinical • Emergent, urgent care centers / facilities, and EMS / paramedics • Medical specialists • Maternity and women / children’s health 18

Multidisciplinary Team Members Related to Care Coordination (Cont’d – 1) • Financial, education, quality improvement, safety, and infection prevention teams • Behavioral / mental health services • Pharmacy and medication management services • Physical therapy and rehabilitation services 19

Multidisciplinary Team Members Related to Care Coordination (Cont’d – 2) • • Case management services Post-acute care programs and services Care transitions Social workers 20

Multidisciplinary Team Members Related to Care Coordination (Cont’d – 3) • • Community-based services Chaplains Patient and Family Advisory Councils (PFACs) Patient and Family Advocates 21

Unit 2: Team-based Approach to Patient Care Summary – Lecture a – Multidisciplinary Care Planning • Team-based care is a proven, preferred model • Trusting relationships and mutual respect are fostered among team members • Patient and family are members of the team • Multidisciplinary collaborative team members combine their aggregate experience, knowledge, intellect, and expert skills 22

Unit 2: Team-based Approach to Patient Care References – Lecture a References PCMH Resource Center. (n. d. ). Retrieved March 9, 2016, from https: //pcmh. ahrq. gov/ Naylor MD, Coburn KD, Kurtzman ET, et al. (2010). Inter-professional team-based primary care for chronically ill adults: State of the science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. Philadelphia, PA Patient and Family Advisory Councils (PFACs) | Health Care For All. (n. d. ). Retrieved March 9, 2016, from https: //www. hcfama. org/patient-and-family-advisory-councils-pfacs 23

Unit 2: Team-based Approach to Patient Care Lecture a – Multidisciplinary Care Planning This material was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90 WT 0006. 24