It's National Primary Care Week! The theme is improving health care access for all. One way we believe that the health care system can do that is through interprofessional team-based care. Many health care providers love the concept, but what to do patients think? That's what we wanted to find out.By Sonya Collins
Ridie Ghezzi was dealing with depression. Her doctor tried her on one medication, then another, then changed her dose, but it just wasn’t working for her. So she called Amanda Rice, the behavioral health specialist at Dartmouth Health Connect in Hanover, NH, where Ghezzi is a patient.
Rice immediately contacted Ghezzi’s primary care doctor – also at Dartmouth Health Connect – who called Ghezzi that day. The phone conversation was long and unhurried. During the call, the doctor decided to change Ghezzi’s prescription, and she made an appointment to meet with Ghezzi, her health coach, and the behavioral health specialist as a team the next month.
“I felt like the wagons had surrounded me in protection,” Ghezzi recalled.
A same-day call back from a doctor? A long phone conversation? An appointment with three health professionals in the room at the same time? If this doesn’t sound like a typical interaction with the health care system, it’s because Dartmouth Health Connect is not a typical clinic. Its team-based model of care strikes a stark contrast to the solo doctor-does-all, seven-minute-visit model that most patients know (and few love).
By design, team-based practices, also called patient-centered medical homes, have the potential to redistribute provider workload, change the way health care providers get paid, and – in the best cases – put patients at the center of it all. Providers have many reasons to love the model of care, but what do patients think?
Research shows that patients want four things in a medical practice: whole-person care; coordination and communication among providers and between providers and patients; patient support and empowerment; and ready access.
If a health care model by any name delivers those benefits, patients are likely to take to it. “Patients love the concept, but if it’s not operationalized, if the practice isn’t visibly operating as a team, they won’t embrace it,” said Christine Bechtel, co-chair of the Center for Patients, Families and Consumers at the Patient-Centered Primary Care Collaborative. Bechtel co-authored the aforementioned research published in 2010 in Health Affairs.
What is team-based care?
The idea behind team-based care is that doctors cannot – and should not – do it all. They can’t see all the patients, solve all the problems, and complete all the associated administrative tasks in a day’s work. Even if they could do it all, they’re not always the best one for the job. Doctors diagnose, but pharmacists unravel complex medication regimens to discover which one is causing the unpleasant side effects. Dietitians help patients come up with a meal plan to achieve a healthy weight or manage their diabetes. Behavioral health specialists address the mental and emotional issues that may prevent us from achieving optimum health. Sure, doctors can refer patients to these and other specialists, but patients don’t always follow through. And when they do, the referring doctor may never know what happened during the visit.
Team-based care can bring multiple health care providers together under one roof, or it can include a care coordinator who quarterbacks care that happens in multiple settings. Team members can free up their teammates to do what they do best, whether it’s diagnose, manage medications, or optimize a diet.
“It’s not about a doctor just writing a prescription and telling you what to do,” said Amy Gibson, RN, who is chief operating officer of the Patient Centered Primary Care Collaborative. “It’s about bringing [providers] together as partners who can provide expertise. At any given point in time, it may be the behavioral health specialist or some other team member besides the physician who needs to be leading that team.”
Placing patients with the most appropriate health care provider, rather than the doctor every time, can also increase access to all providers for all patients. That’s why some team-based models may offer same-day appointments, email and telephone access to providers, and longer appointments. Team-based models may also allow for innovative payment structures. For example, payers might reimburse practices a flat monthly fee per patient rather than a fee for each service provided.When it doesn’t work
Simply declaring a practice to be “team-based” is not enough to convince patients. Bechtel selected her current primary care provider because it was a team-based clinic. She has been a patient there for several years now. But every time she goes, she says she feels like a new patient that no one knows. She fills out paperwork for the receptionist, who asks her why she is there. She then sees the medical assistant (MA), who takes her vitals and asks her why she’s there. The MA then leaves her with a doctor, physician assistant (PA) or nurse practitioner, who again asks her why she is there.
“Where is the team part of this? I’ve just been asked why I’m here three times,” Bechtel said. “It’s so obvious to patients when they’re not operating as a team.”
For patients, a team-based model like this one just seems to place more barriers between their doctors and themselves.
“Oftentimes, what patients observe, unfortunately, is that they can’t get to their doctor because it’s ‘team-based,’” Bechtel said. “They ask, ‘Well, what does that mean?’ And the practice tells you it means that all providers can access the medical record and read each other’s notes. But that’s not a team.” Shared access to an electronic medical record may streamline the workflow for providers, but it’s not necessarily a visible improvement in the patient’s experience.
Even the best intentioned team-based clinics may not get full buy-in from patients if patients don’t know what team-based care is. Patients need to be fully oriented as to what the new model offers, what issues it addresses and how patients can make the most of it.
“If no one ever explains to patients what a team-based approach is, that you might sometimes see a different person, but that person is always going to know what’s happening with you and has full access to your doctor and your records,” Bechtel said. “If no one ever says that, the patient experience isn’t going to be good.”When it works
Team-based care that works puts the patient at the center and addresses the patient’s needs and concerns ahead of those of the provider or payer. “We haven’t done such a good job of knowing and engaging our customer in health care, and we’re trying to make that happen through the patient-centered medical home,” said Gibson.
Whether patients like Ghezzi can cite precisely those four things that research says patients want, the way she describes her experience reflects these values. Her physician teamed up with the behavioral health specialist to address her complaints as a whole person. The providers communicated with each other prior to contacting her and then engaged her in a conversation with them during a group appointment. The quick call-back demonstrated their support for her and her ready access to them.
“Everyone is working together, recognizing that none of these things are separate from each other. Emotional and physical are interconnected,” Ghezzi said. “And you feel, by the kind of care they give, that it’s all being worked on as a whole.”
Is a rose a rose?
Many medical practices can call their model team-based, but that doesn’t predict what the patient’s experience will be. At the same time, whether or not patients even know the name of the model, they will know whether their health care providers are working together as a team with the patient at the center.
“If you build it will they come?” Bechtel asks in the title of her 2010 Health Affairs article on team-based care. The answer, she says, is “if you build it with them, they will already be there.”Sonya Collins is an independent journalist who covers health care and scientific and medical research. She is the editor of Progress Notes. Read more about team-based care.