According to a paper by the National Academy of Medicine (NAM), a healthcare team is a group of healthcare professionals who collaborate and coordinate their actions toward the common goal of providing the best possible health outcomes for a patient. While the health care team consists primarily of licensed professionals who give clinical care, the care team may also include non-clinical members such as a health care team manager. Their roles may not be clinical but are important in a clinical context.

Health care professionals include doctors, physician assistants, registered nurses, pharmacists, clinical lab consultants, certified midwives, occupational therapists, speech therapists, dieticians, social workers, psychologists, and many others who provide direct patient care. In other clinical contexts, they could include an optometrist, orthodontist, dermatologist, and so forth. Altogether, team-based care is about embracing the fact that different professionals are involved in providing optimal care and, therefore, must work together to achieve their objectives. In that case, how does one create a care team health plan?

Involve the Patient

Part of the care team health plan goal is not only to have a team-based approach amongst health care professionals but also to bring the patient into the fold. It is an approach that requires a change in mindset where the patient becomes a member of the team as opposed to one who passively accepts treatment. In doing so, health care providers form a relationship with the patient whereby the patient can take part in transparent communication regarding their care team health plan. Through such dialogue, health care providers can cater to their patient’s ideals and preferences regarding their health.

Elements of a Care Team Health Plan

• A detailed and structured evaluation of the patient’s medical, psychological, social, and functional needs. This is a holistic approach that considers non-pharmacologic, behavioral health issues that may require therapy or counseling support.
• The roles and goals of the care team, including the assigned responsibilities of each care member. The patient should also provide the names and functions of home and community clinical service providers so they can be included in the team’s coordination effort.
• Making the patient aware of the team-based health care plan so that they know that multiple individuals are involved in their treatment. This is so that concerns about the privacy of health records are addressed, and precautions are taken to maintain confidentiality.
• Educating the patient about prescribed treatments and self-management.
• A review of all treatments prescribed to prevent any negative drug interactions. This implies the existence of a shared medication list.
• A systematic approach to ensuring the patient receives their prescribed treatment. For self-medication, a method of oversight should be put in place.

Steps to Create a Care Team Health Plan

Taking into consideration the above elements, here is how you can create a patient-focused care team health plan.

1. Understanding and Defining the Patient’s Goals

Having created a dialogue with the patient, the care provider can begin to detail and track the patient’s goals over time. These goals are to be shared across the care team, who can provide treatment options in line with those goals. Because the goals will be measured continuously, the care team health plan is a living document that will change as the patient crosses different milestones or moves towards the set objectives.

For example, a patient at the best orthodontist may want a healthy bite, a more aesthetically pleasing face, or to stop the progress of periodontitis. It is then up to the care team to set a path forward that includes observable progress. Such goals may include:

• Maintaining proper dental hygiene andndash; adequate brushing and flossing
• Eating healthily and limiting sugars and acidic foods
• Avoiding cigarettes
• Regular orthodontic visits
• Fixing poorly fitted crowns or bridges
• Reducing plaque and the factors that promote its accumulation
• Reduction in periodontal pocket depth in response to treatment

The goals should have metrics attached to them such that the progress is appreciable. Doing so opens up a level of accountability and transparency regarding the care being given. By defining the goals, the patient and caregivers can work together toward them.

2. Laying Out Any Barriers or Hurdles

The next step is identifying any problems that may stop the patient from reaching their goals. For example, in the case of periodontitis, the patient may be unable to quit smoking alone. Or perhaps they have high blood pressure and cannot maintain a consistent exercise routine. Maybe they have acquired the services of a medical exemption lawyer to avert a potential allergic reaction to a vaccine. Ironing out these roadblocks will help the care team health providers to seek alternative solutions sooner rather than later.

3. Symptom Identification

In detail, list the symptoms the patient is experiencing. For periodontitis, this may be bad breath, swollen gums, painful chewing, loose or sensitive teeth, etc.

4. What Interventions Can Be Made

These are the steps taken to achieve the stated goals or outcomes. Therefore interventions could include administering medication, educating the patient on their treatment and prognosis, checking progress indicators, and assessing their symptoms intermittently.

As an example, here are some interventions in the case of high blood pressure:

• Educating the patient on what blood pressure readings mean.
• Reviewing and tracking blood pressure objectives as set by the physician. The patient should be aware of those objectives as well.
• Explaining to the patient the prognosis with treatment.
• Making sure the patient understands the risk factors, such as the relation between sodium and high blood pressure. This way, they will understand the significance of measuring sodium levels and keeping them below a certain threshold.
• Educating the patient on what foods or ingredients to avoid and which to consume.
• Setting optimal lifestyle changes they can achieve, such as regular exercise, and helping them understand how such changes are tied to their health outcomes.
• Similarly, the patient should receive instruction on the roles of each medication in managing high blood pressure.
• Ensuring the patient understands what to do in an emergency and the treatments they may receive if one occurs. For example, a hypertensive emergency would require intravenous therapy and hospitalization. This also gives the patient a say in what life-saving treatments they will receive so that they can raise any concerns beforehand.

A recommendation can be made that the patient seek other forms of treatment, such as a rehabilitation center, if they cannot stop destructive habits such as drinking alcohol.

5. Document All Received Care

For the care team health plan to work, it is necessary that everyone involved in providing health care to the patient is identified and their efforts towards optimal care are documented. There should be an active and ongoing collaboration between patients, their families, and health care providers.

6. Account for Drug Interactions

One of the benefits of having a shared collaboration method is that all caregivers involved are aware of the treatment being given. This gives physicians the information necessary to avoid potentially harmful drug interactions. Similarly, patient allergies should also be documented so that medication dangerous to the patient is not administered. A mistake here could constitute medical negligence and invite bad health outcomes and medical malpractice attorneys.

7. Tracking the Patient’s Progress

Depending on the patient’s ailment, the care team health providers need to have a list of vitals (e.g., BMI and blood pressure) and other progress indicators that they will be measuring and recording periodically. Other progress indicators include lab results such as total cholesterol levels, HgbA1C, and Triglyceride levels for high blood pressure patients.

8. General Outcomes

As opposed to the measurable goals stated earlier, these are more of the quality of life improvements that a patient can expect. These are improvements they could experience given if the treatment works as expected. For a high blood pressure patient, this means living a relatively normal life without worrying about a stroke, heart attack, kidney damage, reduced medication intake, etc. It gives the patient a different future to hope for and work towards.

The Use of Collaborative Tools in Care Team Health Plans

As you can imagine, it isn’t easy to collaborate effectively without technology, especially when patients visit different medical institutions or are referred to other hospitals. Therefore, using tools such as electronic health records, referral trackers, and patient portals is the key to unlocking the full potential of health care team plans. Computerized provider order entry systems allow clinicians to request lab tests, radiology tests, and medication. They can get supplies as needed through automated medical supply systems, for example, colostomy bags from an ostomy supplier. Through a referral tracker, a physician can be aware that a patient visited a medical spa. Using such tools improves the ease with which patients access healthcare and gives caregivers more time to attend to other patients.

Since 2009, primary and behavioral health caregivers in Washington have been collaborating using a web-based registry called the Care Management Tracking System. They use it to integrate behavioral/mental care into primary care so that there is a holistic approach to the health outcomes of patients. A care coordinator manages the data in the registry at the primary practice, ensuring that a patient’s psychiatric consultation data is available to the primary care physician and vice versa.

Values and Principles

According to the Institute of Medicine, the success of a team-based approach to health care plans requires that the team member’s values align. These values include; discipline, honesty, humility, curiosity, and creativity. These values will help the team attain the principles of shared goals, effective communication, well-defined roles, measurable goals and outcomes, and mutual trust. Curiosity and creativity will help the team find new ways to solve problems and learn from poor outcomes. Sticking to these ideals will help the health care team attain continual improvement in their practice.

Similarly, the National Association of Medicine states that a team-based health care plan needs a cohesive effort from all team members. Teams will need:

• A definite and common goal
• A shift in culture geared towards a team effort
• An organizational framework that supports teamwork
• Coaching to facilitate optimal teamwork

Challenges in Providing Team-Based Care

• Patients andndash; Not every patient will be comfortable with having so much input into their care. They may also balk at having more individuals than they are accustomed to handling their case. Many are used to seeing one physician across multiple visits.
• Reimbursement andndash; Current payment services do not properly support the team-based care approach. An example is unequal reimbursement practices whereby health providers offer the same services as a physician but are paid a fraction of what the physician would receive.
• Resistance andndash; Proponents of physician-led care are not too keen on acknowledging the roles of other health care professionals, such as advanced practice registered nurses (APRNs). This violates the values and principles upon which team-based care is founded. A team-based approach requires trust and respect from all players, whether primary caregivers or other health professionals.

Advantages of Team-Based Care

Team-based care can potentially improve the experiences of healthcare professionals and patients. A team-based approach gives patients greater access to healthcare because the team-based approach allows physicians to reach more people and reduces wait times. Patients also get a higher quality of care that includes patient education and behavioral health services. Better outcomes are also achieved through care coordination and self-management support.

Improved outcomes for patients mean that health professionals get more job satisfaction. Team-based care also creates a work environment where each member is encouraged to work to their strengths while relying on the expertise of a larger pool of professionals. This forms a strong backbone for the patient to receive optimal care.

As team-based care continues to spread, healthcare organizations will have to restructure to provide optimal team care. The result is that patients will receive a holistic health care experience that leads to better clinical outcomes. Reach out to us today if you are interested in team-based healthcare plans.