Team-based Health Care Delivery Research Articles

Patient-Centered Care Through Nurse Practitioner-Led Integrated Behavioral Health: A Case Study.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

Medical Emergency Data and Networks: A German-Canadian Comparison.

A significant number of problems in emergency care are caused by a lack of provider access to pre-existing patient information at the point of care. Medical Emergency Datasets (MEDs) are brief summarizations of an individual's medical history, providing vital patient information to emergency medical providers. The German MED was validated by German physicians and - based on an international research project - also by Canadian physicians. Physicians in both countries considered the content very useful. The MED is currently being introduced in Germany as part of the Telematic Infrastructure. At the same time, the COVID pandemic forced healthcare professionals around the work to optimize the digital information exchange among different healthcare providers. While the exchange of data is important, additional personal expert advice is sometimes vital. Real time virtual support systems (RTVS) were introduced in Germany and Canada to support team-based healthcare delivery, independent of the actual location. Such systems have been implemented for intensive care, emergency medicine, primary care and several other medical specialties. These systems serve as a safety net, a funnel (appropriate utilization; linking patients back to primary care networks - thus reducing fragmented or disrupted services) and a medical network by building interprofessional relationships.

Prevalence of Psychiatric Diagnoses and Psychiatric Consultation Service Utilization on Inpatient Medical Units.

This practice improvement project sought to determine the prevalence of psychiatric diagnoses among patients admitted to a community hospital's inpatient medical units and which diagnoses were serviced by the hospital's psychiatric consultation service. Electronic medical record data on adult patients of five medical units admitted with a psychiatric condition between October 1, 2019, and December 31, 2019, were used. Psychiatric ICD-10 (International Classification of Diseases, 10th Revision) codes and diagnosis names extracted were categorized into seven major diagnostic groups. A total of 687 adult patients with 82 psychiatric ICD-10 codes were analyzed using descriptive statistics. Substance-related and addictive disorders were the most prevalent psychiatric diagnoses. Ninety-six percent (n = 658) of patients residing on medical floors with psychiatric disorders were hospitalized for a principal medical problem. Seventy-three cases received psychiatric consultations during their stay. Sixty percent (n = 44) of those cases had psychiatric disorders from two or more diagnostic categories. Multidisciplinary, team-based health care delivery models that include a psychiatric nurse can provide an effective approach to treat patients in community hospitals with multiple psychiatric and medical comorbidities. Hospitals could take a significant role in providing substance use disorder treatment and equipping medical nurses with training to competently care for patients with psychiatric disorders on medical units. Further research into the prevalence and impact of patients with co-occurring and multiple psychiatric diagnoses in community hospitals is needed to implement effective health care delivery models and provide appropriate treatment options in the community.

Is North Carolina's Workforce Prepared for Team-Based Care?

Evaluating the capacity of the health workforce to adopt team-based health care delivery models, nationally or in North Carolina, requires a nuanced approach that explores educational and clinical environments, payment, health systems, and regulatory levers. This paper discusses workforce challenges to team-based care and how best to train, prepare, and retool an equipped health workforce to meet the needs of team-based care.

Perceptions, practice, and “ownership:” experiences in continuity of the patient-doctor relationship in a family medicine residency

The objective of this mixed-methods study was to determine interpersonal continuity (the ongoing therapeutic relationship between patient and health care provider) experiences of family medicine residents and preceptors, and explore their perceptions of interpersonal continuity. Quantitative data on resident and preceptor encounters were extracted from the electronic medical record (EMR). Opportunities for developing interpersonal continuity were determined using the Usual Provider Continuity (UPC) Index. A qualitative descriptive research method was used for the qualitative portion. Semi-structured interviews were conducted and constant comparative analysis was used to determine emerging themes. Residents were found to have low UPC rates; preceptor rates were higher. Qualitative findings showed variable experiences with interpersonal continuity not apparent from UPC rates. Both preceptors and residents expressed perception of "ownership" of patients as a significant barrier to interpersonal continuity. This study suggests that a perceived lack of individual "ownership" of a patient panel was a significant barrier to developing interpersonal continuity. This might conflict with current changes towards team-based health care delivery. Understanding perceptions and changing them through a multi-faceted approach including resident teaching and faculty development might help improve interpersonal continuity which are core to both family medicine curricula and current models of health care delivery.

Pharmacist-Driven Strategies for Hypertension Management in Los Angeles: A Community and Stakeholder Needs Assessment, 2014-2015.

In 2014, the Los Angeles County Department of Public Health received federal funding to improve the prevention and control of hypertension in the population through team-based health care delivery models, such as pharmacist-led medication therapy management. To inform this work, the department conducted a 3-part needs assessment consisting of 1) a targeted context scan of regional policies and efforts, 2) a key stakeholder survey, and 3) a public opinion internet-panel survey of Los Angeles residents. Results suggest that political will and professional readiness exists for expansion of pharmacist-led medication management strategies in Los Angeles. However, several infrastructure and economic barriers, such as a lack of sufficient payment or reimbursement mechanisms for these services, impede progress. The department is using assessment results to address barriers and shape efforts in scaling up pharmacist-led programming in Los Angeles.

Progresses and challenges of utilizing traditional birth attendants in maternal and child health in Nigeria.

Background and Introduction:Emigration of healthcare workers from developing countries is on the rise and there is an urgent need for policies that increase access to and continuity of healthcare. In this commentary, we highlight some of the negative impacts of emigration on maternal and child health and discuss whether team-based healthcare delivery could possibly mitigate the shortfall of maternal and child health professionals in developing countries.Methodology:We cross-examine the availability of supporting structures to implement team-based maternal and child healthcare delivery in developing countries. We briefly discuss three key supporting structures: culture of sharing, telecommunication, and inter-professional education. Supporting structures are examined at system, organizational and individual levels. We argue that the culture of sharing, limited barriers to inter-professional education and increasing access to telecommunication will be advantageous to implementing team-based healthcare delivery in developing countries.Conclusion and Global Health Implications:Although most developing countries may have notable supporting structures to implement team-based healthcare delivery, the effectiveness of such models in terms of cost, time and infrastructure in resource limited settings is still to be evaluated. Hence, we call on usual stakeholders, government, regulatory colleges and professional associations in countries with longstanding emigration of maternal and child healthcare workers to invest in establishing comprehensive models needed to guide the development, implementation and evaluation of team-based maternal and child healthcare delivery.

The implementation of a Community Health Centre-based primary care model in Italy. The experience of the Case della Salute in the Emilia-Romagna Region.

The Comunity Health Centre (CHC) primary care model is a team-based health care delivery model intended to provide comprehensive and continuous medical care to patients within a defined community. The CHC, Case della Salute in Italian, model was introduced in the Emilia-Romagna Region in 2010. We present updated data on the implementation on the CHC Case della Salute primary care model in the Emilia-Romagna Region. There are 67 operating CHCs in Emilia-Romagna (update March 2015); 26 small (39%), 24 medium (36%) and 17 large (25%). Since 2011 the number of operating CHCs has increased by 60%, reaching 55% of the target planned CHCs (n. = 122). There is, on average, one running CHC per 66.524 inhabitants. 16% of total general practitioners (GPs) and 8.4% of total family paediatricians working in Emilia-Romagna have their practice in CHCs. CHCs offer primary and specialist integrated care, prevention services, health education and social care. Although preliminary results suggest CHCs have fostered primary care's quality and efficiency, more research is needed to assess their impact on improving clinical, social and economic outcomes.

Partnership to promote interprofessional education and practice for population and public health informatics: A case study

Team-based healthcare delivery models, which emphasize care coordination, patient engagement, and utilization of health information technology, are emerging. To achieve these models, expertise in interprofessional education, collaborative practice across professions, and informatics is essential. This case study from informatics programs in the Academic Health Center (AHC) at the University of Minnesota and the Office of Health Information Technology (OHIT) at the Minnesota Department of Health presents an academic–practice partnership, which focuses on both interprofessionalism and informatics. Outcomes include the Minnesota Framework for Interprofessional Biomedical Health Informatics, comprising collaborative curriculum development, teaching and research, practicums to promote competencies, service to advance biomedical health informatics, and collaborative environments to facilitate a learning health system. Details on these Framework categories are presented. Partnership success is due to interprofessional connections created with emphasis on informatics and to committed leadership across partners. A limitation of this collaboration is the need for formal agreements outlining resources and roles, which are vital for sustainability. This partnership addresses a recommendation on the future of interprofessionalism: that both education and practice sectors be attuned to each other’s expectations and evolving trends. Success strategies and lessons learned from collaborations, such as that of the AHC-OHIT that promote both interprofessionalism and informatics, need to be shared.

Caring With Compassion, Domain 2: Bio-Psychosocial Care of Uninsured, Homeless, Underserved, and At-Risk Populations

Abstract Introduction The Caring with Compassion series provides core background information to support bio-psychosocial clinical care for homeless, underserved, uninsured, and at-risk populations....

Applying organizational science to health care: a framework for collaborative practice.

Developing interprofessional education (IPE) curricula that improve collaborative practice across professions has proven challenging. A theoretical basis for understanding collaborative practice in health care settings is needed to guide the education and evaluation of health professions trainees and practitioners and support the team-based delivery of care. IPE should incorporate theory-driven, evidence-based methods and build competency toward effective collaboration.In this article, the authors review several concepts from the organizational science literature and propose using these as a framework for understanding how health care teams function. Specifically, they outline the team process model of action and planning phases in collaborative work; discuss leadership and followership, including how locus (a leader's integration into a team's usual work) and formality (a leader's responsibility conferred by the traditional hierarchy) affect team functions; and describe dynamic delegation, an approach to conceptualizing escalation and delegation within health care teams. For each concept, they identify competencies for knowledge, attitudes, and behaviors to aid in the development of innovative curricula to improve collaborative practice. They suggest that gaining an understanding of these principles will prepare health care trainees, whether team leaders or members, to analyze team performance, adapt behaviors that improve collaboration, and create team-based health care delivery processes that lead to improved clinical outcomes.

Teaching Interprofessionalism to Nursing Students:A Learning Experience Based on Allport's Intergroup Contact Theory

FACULTY SEEKING TO CREATE LEARNING ACTIVITIES THAT FACILITATE EXPOSURE TO AND ENHANCE THE LEARNING OF INTERPROFESSIONAL (IP) HEALTH CARE TEAM BEHAVIORS WILL BENEFIT FROM AN UNDERSTANDING OF GROUP PROCESSES AS ADVOCATED BY SOCIAL SCIENTIST GORDON ALLPORT. In 1954, Allport postulated that prejudice or stereotyping within groups can interfere with the successful functioning of groups, and that just putting individuals together and expecting them to function is not enough (Pettigrew, 1998). Today's nursing students must be academically and experientially prepared to participate in the IP environment in order to assimilate the roles expected by employers and provide the highest quality patient care (Lindqvist & Reeves, 2007; Sullivan & Godfrey, 2012). However, while interprofessionalism is inherent in what nurses do every day in performing their job, there is often little focus on IP within nursing education. As the system of delivery of health care services changes to include the IP health care team process, the educational preparation of health care providers will have to evolve (Gillespie & McFetridge, 2006). This article provides a brief theoretical framework to support the development of team-oriented thinking and behavior through the use of faculty-guided learning experiences whereby nursing students can learn the skills necessary for working in IP health care teams. An example of a learning experience that can take place early in the student's nursing education, in a didactic setting, is provided. Barriers to Interprofessionalism The IP health care team is characterized as a group of health care professionals from various disciplines who share the responsibility of collaborative decision-making to achieve desired patient goals (McCallin & Bamford, 2007). A distinct focus on team-based health care delivery allows this group to address complex patient needs within a structure that also considers the full spectrum of care, including quality of service, its cost, and access to health care. The goal of the team partnership is joint decision-making to achieve patient-centered outcomes using collaborative knowledge, skills, and varied professional perspectives (Jansen, 2008; Johanson, 2008, Royeen, Jensen, & Harvan, 2009). Working under such complex conditions requires collaboration, team decision-making, and assertiveness and self-confidence, as well as a balance between one's profession and the team activities (Atwal & Caldwell, 2006; Kvarnstrom, 2008; Young, Baker, Waller, Hodgson, & Moor, 2007). However, researchers have identified barriers to the team approach, including varying perceptions of teamwork, differing ability levels in team members, stereotyping behaviors, and the potential for one profession, specifically medicine, to exert dominance over the others (Atwal & Caldwell; Gilbert, 2005; Royeen et al., 2009). McCallin and Bamford (2007) suggested that to change stereotypical perceptions attached to other professions, team members use communication techniques such as pluralistic dialoguing, which recognizes and respects the notion that alternative points of view have merit. Participants in this mode of communication are open to various perspectives and have a good understanding of the roles and skills of other practitioners. Interprofessional Education and AIIport's Intergroup Contact Hypothesis In an academic environment that seeks to promote IP education, simply creating a class roster of students from various professions and expecting the students to accept the perspectives of the individual professions represented in the class are not sufficient to create the attitudes necessary to function as an IP team in providing patient care (Lidskog, Lo, Mark, & Ahlstrom, 2007). Allport's intergroup contact hypothesis holds that prejudice can be reduced within and among groups and that there can be positive attitude changes in a group if certain elements exist. …

Communication Commentary: It Takes a Village: Effective Interprofessional Collaboration in Health Care Teams

Health care is changing. The technologies available for diagnostics are improving. The methods of acquiring and sharing information are burgeoning with the advent of the electronic medical record and information technology. Care is expected to be patient-centered, ensuring that the patient and familyunderstandtheoptionsavailable for treatment and are the decision-makers guiding care. In addition, health care is increasingly team-based. A broadly accepted definition of team-based health care is “the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care” (1). “The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system” (2, p. 3). With the literature burgeoning with new research findings, and with the research evidence that serves as the metric for quality of care continually changing, no single physician can absorb all of this information. Physicians must rely on specialists in other fields. Patient consumers are frequent utilizers of physician services. For example, the “typical Medicare beneficiary visits two primary care clinicians and five specialists per year,” as well as utilizing the ancillary services of diagnostic radiology, laboratory testing, pharmacy, and other services (3). Individuals suffering frommultiple

The Environmental Context of Absorptive Capacity for Collaborative Care Management

Absorptive capacity is a theoretically and practically useful framework for both understanding and informing the acquisition, assimilation and exploitation of innovations within organizations. In this conceptual paper, we expand the context of absorptive capacity to include environmental factors, drawing on both resource dependency theory and institutional theory, to better understand their role within the absorptive capacity process. We utilize Collaborative Care Management, a cost effective, team-based healthcare delivery model for depression patients, as a case study to explore relevant environmental constructs within the proposed framework, including power, legitimacy, regulations, norms, and beliefs. Based on a series of propositions from this conceptual analysis, we present existing research that has addressed aspects of the propositions and propose new approaches to incorporate the environment within studies of absorptive capacity. As the United States health care field enters an era of new delivery models and potentially systematic changes, it is critical to understand how organizations absorb these changes and how the environment affects their absorptive capacity.

Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research.

BackgroundThere are no empirically-grounded criteria or tools to define or benchmark the quality of outpatient clinical documentation. Outpatient clinical notes document care, communicate treatment plans and support patient safety, medical education, medico-legal investigations and reimbursement. Accurately describing and assessing quality of clinical documentation is a necessary improvement in an increasingly team-based healthcare delivery system. In this paper we describe the quality of outpatient clinical notes from the perspective of multiple stakeholders.MethodsUsing purposeful sampling for maximum diversity, we conducted focus groups and individual interviews with clinicians, nursing and ancillary staff, patients, and healthcare administrators at six federal health care facilities between 2009 and 2011. All sessions were audio-recorded, transcribed and qualitatively analyzed using open, axial and selective coding.ResultsThe 163 participants included 61 clinicians, 52 nurse/ancillary staff, 31 patients and 19 administrative staff. Three organizing themes emerged: 1) characteristics of quality in clinical notes, 2) desired elements within the clinical notes and 3) system supports to improve the quality of clinical notes. We identified 11 codes to describe characteristics of clinical notes, 20 codes to describe desired elements in quality clinical notes and 11 codes to describe clinical system elements that support quality when writing clinical notes. While there was substantial overlap between the aspects of quality described by the four stakeholder groups, only clinicians and administrators identified ease of translation into billing codes as an important characteristic of a quality note. Only patients rated prioritization of their medical problems as an aspect of quality. Nurses included care and education delivered to the patient, information added by the patient, interdisciplinary information, and infection alerts as important content.ConclusionsPerspectives of these four stakeholder groups provide a comprehensive description of quality in outpatient clinical documentation. The resulting description of characteristics and content necessary for quality notes provides a research-based foundation for assessing the quality of clinical documentation in outpatient health care settings.

Severe Shortage of Physicians Expected by End of Decade

Back to table of contents Previous article Next article Professional NewsFull AccessSevere Shortage of Physicians Expected by End of DecadeEve BenderEve BenderSearch for more papers by this authorPublished Online:2 Nov 2012https://doi.org/10.1176/pn.47.21.psychnews_47_21_1-bAbstractProjected physician workforce shortages show the urgent need for an increase in federally funded physician training to meet rapidly increasing patient needs, according to recommendations issued by the Association of American Medical Colleges (AAMC) in September. According to AAMC estimates, the United States faces a shortage of more than 90,000 physicians by 2020—a number that will grow to more than 130,000 by 2025 if no action is taken.The June Supreme Court decision to uphold the Affordable Care Act (ACA) means that an additional 32 million Americans may become newly insured and will have greater demands for health care as they age. According to AAMC estimates, as Americans gain medical coverage through Medicare and expanded access to private insurance, the United States is projected to confront a shortage of 91,500 doctors by 2020.The Balanced Budget Act of 1997 capped Medicare-funded graduate medical education (GME) for the vast majority of teaching hospitals and continues to limit the establishment of new residency training programs, the AAMC pointed out. While the ACA did not eliminate the cap, it funded the training of approximately 300 additional physicians annually—which would have a minor impact on the looming physician shortage.The AAMC recommendations call for an increase in federally funded GME training positions of 4,000 a year to meet the population’s increasing medical needs. This increase would boost the influx of new physicians by about 30,000 by the end of the decade, which would compensate for about a third of the expected shortage.Half of the 4,000 new residency positions added annually should be allotted to primary care and generalist disciplines, with the other half divided among approximately 140 medical specialties, according to the AAMC, which also emphasized that a team-based health care delivery model would further improve access to medical services. As a fragmented health care system becomes team based and thus better integrated, newly insured patients would depend on their primary care physicians to coordinate care with specialists for certain medical conditions.The AAMC recommendations also call for increased reimbursement of physicians who serve in geographically remote or economically disadvantaged areas and for federal funding of innovative health care delivery research.Rep. Joseph Crowley (D-N.Y.) in September introduced H.R. 6562, the Resident Physician Shortage Reduction Act of 2012, which would add 3,000 additional Medicare-supported residency positions annually over a five-year span. In a press release announcing the bill, Crowley noted that “we face a cruel irony: retiring baby boomers and the newly insured, now covered through the Affordable Care Act, will be accessing our health care system in greater numbers, but we won’t have nearly enough doctors on-the-ready to deliver the health care services they’ll need…. A doctor shortage is something we just can’t ignore.”How will this expansion of residency positions affect the field of psychiatry? According to Sidney Weissman, M.D., a professor of clinical psychiatry at Feinberg School of Medicine at Northwestern University and a former member of APA’s Board of Trustees, “the addition of 4,000 more residency positions per year is negligible—especially when divided between generalist and specialty positions.”While the number of U.S. medical graduates is expected to increase by as much as 30 percent by the end of this decade, the number of residency positions available by that time would only have increased by 16 percent, even with the addition of new positions, Weissman said. Half of that increase in the number of residency positions would be divided among all of the medical specialty residency programs, and half would be allocated to primary care and generalist residencies. Since all medical specialty residency programs combined usually attract a higher proportion of medical graduates than do generalist programs, there will be more intense competition for most of the specialty programs.What these scenarios foretell, Weissman told Psychiatric News, is an increased number of medical graduates entering psychiatry residency programs (and other specialty training programs) for whom psychiatry is not their initial career choice, but perhaps their second or third choice. “Ultimately, medical graduates will have more complex decisions to make about their career paths due to the fact that they may not be able to train in their preferred specialty,” Weissman said. He does not think that this will, however, have a negative impact on any of the specialty medical fields. The AAMC Physician Workforce Policy Recommendations are posted at www.aamc.org/download/304026/data/2012aamcworkforcepolicyrecommendations.pdf. Crowley’s bill, HR 6562, is posted at http://thomas.loc.gov/cgi-bin/bdquery/z?d112:h.r.6562:. ISSUES NewArchived

Collaboration, Credibility, Compassion, and Coordination: Professional Nurse Communication Skill Sets in Health Care Team Interactions

This study explored how nurses communicate professionalism in interactions with members of their health care teams. Extant research show that effective team communication is a vital aspect of a positive nursing practice environment, a setting that has been linked to enhanced patient outcomes. Although communication principles are emphasized in nursing education as an important component of professional nursing practice, actual nurse interaction skills in team-based health care delivery remain understudied. Qualitative analysis of interview transcripts with 50 participants at a large tertiary hospital revealed four communicative skill sets exemplified by nursing professionals: collaboration, credibility, compassion, and coordination. Study findings highlight specific communicative behaviors associated with each skill set that exemplify nurse professionalism to members of health care teams. Theoretical and pragmatic conclusions are drawn regarding the communicative responsibilities of professional nurses in health care teams. Specific interaction techniques that nurses could use in nurse-team communication are then offered for use in baccalaureate curriculum and organizational in-service education.