Team-based Patient Care Research Articles

Implementation challenges in delivering team-based care ('TEAMcare') for patients with chronic obstructive pulmonary disease in a public hospital setting: a mixed methods approach.

BackgroundChronic obstructive pulmonary disease (COPD) is considered a multisystem disease, in which comorbidities feature prominently. COPD guidelines recommend holistic assessment and management of relevant comorbid diseases but there is limited information as to how this is best achieved. This pilot study aimed to explore the views of stakeholders, including patients and the healthcare team, on the feasibility, acceptability and barriers to a collaborative, multidisciplinary team-based care intervention (‘TEAMcare’) to improve health outcomes in COPD patients, within the context of a local hospital outpatient clinic.MethodsA mixed methods study design was used. A COPD care algorithm was developed based on the Australasian guidelines, COPDX. COPD participants were consecutively recruited from an outer metropolitan hospital’s respiratory clinic. Participants attended for follow up visits at 5 and 10 months to ascertain clinical status, algorithm compliance and to review and revise management recommendations. The intervention was conducted using existing resources, involving collaboration with general practice and the publicly-funded local chronic disease management programme (Medicare Local). Stakeholders provided qualitative feedback about the intervention in terms of feasibility, acceptability and barriers via structured and semi-structured interviews. All interviews were recorded, transcribed verbatim and analysed using qualitative thematic analysis to identify key concepts and themes.ResultsThe study protocol was abandoned prematurely due to clear lack of feasibility. Of 12 participants, 4 withdrew and none completed pulmonary rehabilitation (PR). The main reasons for non-participation or study withdrawal related to reluctance to attend PR (6 of 16) and the burden of increased appointments (4 of 16). PR conflicted with employment hours, which presented problems for some participants. Similarly, themes that emerged from qualitative data indicate healthcare provider perception of deficiencies in funding (for infrastructure and staffing). Health literacy, motivation, organisation and functional impairment were issues for patients.ConclusionsAvailable data from this small pilot provided valuable insights to inform future design and implementation strategies. Delivering structured team-based care to COPD patients presents challenges. In addition to enhancing health resources for engaging COPD patients, a focus on health literacy and improving health service access, including colocalisation and access outside business hours, may be required.Trial RegistrationACTRN12616000342415; 16/03/2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1592-2) contains supplementary material, which is available to authorized users.

Collaboration and entanglement: An actor-network theory analysis of team-based intraprofessional care for patients with advanced heart failure

Despite calls for more interprofessional and intraprofessional team-based approaches in healthcare, we lack sufficient understanding of how this happens in the context of patient care teams. This multi-perspective, team-based interview study examined how medical teams negotiated collaborative tensions. From 2011 to 2013, 50 patients across five sites in three Canadian provinces were interviewed about their care experiences and were asked to identify members of their health care teams. Patient-identified team members were subsequently interviewed to form 50 “Team Sampling Units” (TSUs), consisting of 209 interviews with patients, caregivers and healthcare providers. Results are gathered from a focused analysis of 13 TSUs where intraprofessional collaborative tensions involved treating fluid overload, or edema, a common HF symptom. Drawing on actor-network theory (ANT), the analysis focused on intraprofessional collaboration between specialty care teams in cardiology and nephrology. The study found that despite a shared narrative of common purpose between cardiology teams and nephrology teams, fluid management tools and techniques formed sites of collaborative tension. In particular, care activities involved asynchronous clinical interpretations, geographically distributed specialist care, fragmented forms of communication, and uncertainty due to clinical complexity. Teams ‘disentangled’ fluid in order to focus on its physiological function and mobilisation. Teams also used distinct ‘framings’ of fluid management that created perceived collaborative tensions. This study advances collaborative entanglement as a conceptual framework for understanding, teaching, and potentially ameliorating some of the tensions that manifest during intraprofessional care for patients with complex, chronic disease.

The Cardiovascular Intensive Care Unit-An Evolving Model for Health Care Delivery.

Prior to the advent of the coronary care unit (CCU), patients having an acute myocardial infarction (AMI) were managed on the general medicine wards with reported mortality rates of greater than 30%. The first CCUs are believed to be responsible for reducing mortality attributed to AMI by as much as 40%. This drastic improvement can be attributed to both advances in medical technology and in the process of health care delivery. Evolving considerably since the 1960s, the CCU is now more appropriately labeled as a cardiac intensive care unit (CICU) and represents a comprehensive system designed for the care of patients with an array of advanced cardiovascular disease, an entity that reaches far beyond its early association with AMI. Grouping of patients by diagnosis to a common physical space, dedicated teams of health care providers, as well as the development and implementation of evidence-based treatment algorithms have resulted in the delivery of safer, more efficient care, and most importantly better patient outcomes. The CICU serves as a platform for an integrated, team-based patient care delivery system that addresses a broad spectrum of patient needs. Lessons learned from this model can be broadly applied to address the urgent need to improve outcomes and efficiency in a variety of health care settings.

Pilot Study of "Japanese Model of Asheville Project"～How Did It Work?

For prevention of the aggravation of diabetic nephropathy, a treatment method that combines self-care with medical guidance is becoming increasingly important, leading to the development of programs for lifestyle modification for the patients. To assess the effectiveness of such programs, we have conducted a feasibility study of a patient self-care support program with medical collaboration by registered pharmacists in community pharmacies involving patients with diabetic nephropathy who are under treatment at medical institutions, including our hospital. This study evaluated the two primary measurements, which are A) the actual execution rate versus planned programs, and B) the patient satisfaction rate. In addition, the achievement rate of behavioral objectives, satisfaction rate of diabetes treatment, degree of concerns (Diabetes Treatment Satisfaction Questionnaire; DTSQ, Problem Areas in Diabetes; PAID) and other physiological indicators have been evaluated. With the approval of the IRB at Kitasato University, sixteen out of 18 patients have continued to participate in the support program, and the study has shown high patient satisfaction with pharmacist coaching support. Patients have gained interest in managing their lifestyles, thereby increasing self-efficacy. Also, information shared between the pharmacists and the physicians has clarified patients' issues and concerns pertaining to their lifestyles, which were effectively utilized in the coaching program. Through meetings with pharmacists, patients have been reassured of the expertise of the pharmacist and thus gained mutual trust, which leads to the patient's behavioral change. We believe that the collaboration of patients, pharmacists and physicians has resulted in effective team-based patient care.

Team-based Care for Patients Hospitalized with Heart Failure.

Hospitalizations for acute heart failure (HF) and subsequent readmissions have received increased attention because of the burden they place on patients, providers, and the health care system. These hospitalizations represent a significant portion of the total cost of HF care and health care in general. Although much of the care of the patient with HF occurs outside of the hospital, the genesis of the programs that attempt to limit repeat hospitalizations begin in the impatient setting. By using evidence-based guidelines, interdisciplinary teams, and comprehensive discharge planning, costly readmissions can be reduced and outcomes improved.

Innovative interprofessional geriatric education for medical and nursing students: focus on transitions in care.

Interprofessional education (IPE) is crucial in fostering effective collaboration and optimal team-based patient care, all of which improve patient care and outcomes. Appropriate interprofessional communication is especially important in geriatrics where patients are vulnerable to adverse effects across the care continuum. Transitions in geriatric care are complex, involving several disciplines and requiring careful coordination. As part of the University of Virginia's initiative on IPE, we developed and implemented an interprofessional geriatric education workshop for nursing and medical students with a focus on transitions in care. A total of 254 students (144 medical students, 107 nursing students and 3 unknown) participated in a 90-min interactive, case-based workshop. Nursing and medical faculty facilitated the monthly workshops with small groups of medical and nursing students over 1 year. Self-perceived competencies in IPE skills and attitudes toward interprofessional teamwork were measured through post-workshop surveys. Data were analyzed using descriptive and nonparametric statistics, excluding the three unknown students. Over 90% of students were better able to describe the necessary interprofessional communication needed to develop a patient-centered care plan in transitioning patients between clinical sites. Four out of five students reported an enhanced appreciation of interprofessional teamwork. They were also able to identify legal, financial and social implications in transitions of care (75%). Nursing students consistently rated the workshop more highly than medical students across most domains (P < 0.05). Students improved and demonstrated their knowledge of interprofessional communication and teamwork skills required in transitions of geriatric care. Introducing these concepts in medical and nursing training may help in fostering effective interprofessional communication and collaboration.

Collaboration between Pharmacists and Physicians Can Improve Patient Care

There are currently an estimated 56 million patients in the United States who do not have adequate access to primary health care. Pharmacists play an essential role in team-based patient care because of patients' reliance on medications to reduce disease-related complications. This article presents data from an ongoing evaluation of a collaborative practice model among physicians and pharmacists that provides care for patients with chronic disease in an urban safety net clinic.

Observations: What Does "Proficient" in Quality Improvement and Patient Safety Look Like?

What does it mean to be proficient? The Association of American Medical Colleges (AAMC)1,2 and the Accreditation Council for Graduate Medical Education (ACGME)3 identify a “proficient” teaching faculty as the cornerstone of resident education in quality improvement and patient safety (QI/PS). The AAMC states that “all clinical faculty need to be proficient . . .”1 Likewise, the ACGME states that its focus is on “the proportion of faculty members who report to be proficient in the application of principles and practices of patient safety.”3 Clinical Learning Environment Review (CLER) site visitors will ask the teaching faculty, “Are you proficient in the application and principles of QI/PS?” But how can they be expected to answer that question until we plainly define what it means to be “proficient”? As leaders in graduate medical education, we cannot aim for a “proficient” teaching faculty until the targets have been clearly identified. Currently, there are no practical definitions of QI/PS proficiency in the literature. Although the AAMC tried to provide one in its “Competencies and the Path to Mastery in Quality and Patient Safety,”2 their proposed definition has noticeable shortcomings: The Milestones themselves are far too nonspecific to be useful to the average member of the teaching faculty (ie, “Applies improvement methodologies to populations”2). They do not provide clear examples of what it means to be “proficient.” Two important QI/PS competencies from the domain of Interpersonal and Communication Skills4 were overlooked. These competencies can be tied directly to transitions in patient care and team-based patient care activities, both of which are integral to being “proficient” in QI/PS. The Milestones focus strictly on faculty achievement and ignore physician development. The QI/PS competencies need to be cultivated over time, starting in the early medical school years. This requires Milestones for each stage of advancement. The AAMC is to be commended for producing the first effort to define faculty proficiency in QI/PS. Clearly, though, there is still a lot of work to be done. We need carefully selected competencies and easily understood Milestones that define QI/PS aptitude for each stage of physician development. Until then, the road map to becoming “proficient” will be indecipherable—and the teaching faculty's response to the CLER field representative's question will be unreliable at best.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind.

Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species. We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care. We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations. New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities. The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.

Introduction to Nutrition Education in Training Medical and Other Health Care Professionals

Advances in science increasingly provide robust evidence documenting the centrality of good nutrition and healthy lifestyle practices in the prevention of chronic diseases to benefit all patients in the health care system. Federal policies such as the Patient Protection and Affordable Care Act (ACA) of 2010 and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, as well as calls for action by professional societies, have endorsed the importance of nutrition in promoting better health outcomes. The recent report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines includes specific recommendations for diet and lifestyle changes that require fundamental knowledge and understanding of nutrition and physical activity for effective implementation (1). Physicians play a key role in the health care system both individually and as team members along with other health care professionals in the delivery of quality health care. With each patient encounter, physicians are positioned on the front lines to increase awareness and personalize the importance of adopting good nutrition and lifestyle practices for the prevention and treatment of disease. They also are very credible advocates for other health care professionals and policy makers in achieving the integration of nutrition throughout the health care system. A core tenet of this supplement issue is that deeper, more systemswide knowledge of nutrition and competency in its application are fundamental to effective team-based patient care. Although the importance of nutrition may be acknowledged, the education and training needed to effectively influence patient care within and between disciplines is lacking (reviewed in reference 2). To initiate systemswide change, the current model for nutrition education of health care professionals must be modified. This supplement issue proposes a framework developed by a multidisciplinary team of health and nutrition educators, clinicians, policy makers, and analysts designed to implement and evaluate a contemporary, synergistic nutrition education curriculum for health care professionals. It advocates for common core nutrition knowledge and practice competencies and recognizes and differentiates the unique skills and talents inherent among the broad range of relevant health care professionals. Consistent with current trends in medical education, nutrition education and training must include an appreciation for team-based, interprofessional patient care. Finally, there is a need for research to evaluate the effectiveness of innovative teaching strategies and how best to implement the new curriculum and assess its effects on patient and population health. The success of this endeavor depends on active engagement and deep commitment of all stakeholders accompanied by resources and incentives to drive this needed change. Numerous organizations and agencies have ongoing activities that advocate for changing the curriculum for health care professionals. The impetus for this supplement issue was a meeting entitled “Future Directions for Implementing Nutrition across the Continuum of Medical Education, Training, and Research,” which was convened by the National Heart, Lung, and Blood Institute (NHLBI), Division of Cardiovascular Sciences, and cosponsored by the NIH Office of Disease Prevention and Division of Nutrition Research Coordination in September 2012. An important outcome of the meeting was that recommendations were made to implement nutrition across the continuum of medical and health care profession education, training, and research. Working groups met to discuss how best to effectively implement nutrition education for medical and all health care professions. This supplement issue is the result and presents our view of the needs and best practices for thoughtful and culturally sensitive change across the continuum of health care education.

Smith promotes pharmacists while at CMS Innovation Center

The rollout of the Affordable Care Act (ACA) has been for many a challenge, but Marie Smith, PharmD, says a recent stint examining policy options for new health care delivery and payment models convinced her this could be a time when pharmacists are positioned for greater roles in team-based patient care.

National Standards in Pathology Education: Developing Competencies for Integrated Medical School Curricula

Medical school education has evolved from department-specific memorization of facts to an integrated curriculum presenting knowledge in a contextual manner across traditional disciplines, integrating information, improving retention, and facilitating application to clinical practice. Integration occurs throughout medical school using live data-sharing technologies, thereby providing the student with a framework for lifelong active learning. Incorporation of educational teams during medical school prepares students for team-based patient care, which is also required for pay-for-performance models used in accountable care organizations. To develop learning objectives for teaching pathology to medical students. Given the rapid expansion of basic science knowledge of human development, normal function, and pathobiology, it is neither possible nor desirable for faculty to teach, and students to retain, this vast amount of information. Courses teaching the essentials in context and engaging students in the learning process enable them to become lifelong learners. An appreciation of pathobiology and the role of laboratory medicine underlies the modern practice of medicine. As such, all medical students need to acquire 3 basic competencies in pathology: an understanding of disease mechanisms, integration of mechanisms into organ system pathology, and application of pathobiology to diagnostic medicine. We propose the development of 3 specific competencies in pathology to be implemented nationwide, aimed at disease mechanisms/processes, organ system pathology, and application to diagnostic medicine. Each competency will include learning objectives and a means to assess acquisition, integration, and application of knowledge. The learning objectives are designed to be a living document managed (curated) by a group of pathologists representing Liaison Committee on Medical Education-accredited medical schools nationally. Development of a coherent set of learning objectives will assist medical students nationally to gain the basic competencies in pathology necessary for clinical practice. Having national standards for competencies preserves schools' independence in specific curriculum design while assuring all students meet the evolving needs of medical practice.

Selecting Tomorrow’s Physicians

Recent U.S. health care reform efforts have focused on three main goals: improving health care for individuals, improving population health, and lowering costs. Physicians, who traditionally have practiced with considerable autonomy, will be required to become members of the team-based patient care models necessary to achieve these goals. In this perspective, the authors assert that medical school admissions, the selection of the future physician workforce, is a key component of health care reform. They review the historical context for medical school admission processes, which have placed a premium on grades and standardized test scores, and examine how admission practices are undergoing fundamental changes in order to select physicians with both the academic and interpersonal and intrapersonal competencies necessary to operate in the health care system of the future. The authors describe how new techniques, such as holistic review and multiple mini-interviews, are contributing to the shift toward competency-based medical education. Innovations underway at the Association of American Medical Colleges to transform medical school admissions also are explored. The authors conclude by arguing that although the admission process has great potential to transform the future health care workforce, major overhauls of the health care payment and delivery systems must be achieved alongside innovations in health professions education to truly transform the U.S. health care system.

Evaluation of an Enhanced Role-Based Access Control model to manage information access in collaborative processes for a statewide clinical education program

BackgroundManaging information access in collaborative processes is a critical requirement to team-based biomedical research, clinical education, and patient care. We have previously developed a computation model, Enhanced Role-Based Access Control (EnhancedRBAC), and applied it to coordinate information access in the combined context of team collaboration and workflow for the New York State HIV Clinical Education Initiative (CEI) program. We report in this paper an evaluation study to assess the effectiveness of the EnhancedRBAC model for information access management in collaborative processes when applied to CEI. MethodsWe designed a cross-sectional study and performed two sets of measurement: (1) degree of agreement between EnhancedRBAC and a control system CEIAdmin based on 9152 study cases, and (2) effectiveness of EnhancedRBAC in terms of sensitivity, specificity, and accuracy based on a gold-standard with 512 sample cases developed by a human expert panel. We applied stratified random sampling, partial factorial design, and blocked randomization to ensure a representative case sample and a high-quality gold-standard. ResultsWith the kappa statistics of four comparisons in the range of 0.80–0.89, EnhancedRBAC has demonstrated a high level of agreement with CEIAdmin. When evaluated against the gold-standard, EnhancedRBAC has achieved sensitivities in the range of 97–100%, specificities at the level of 100%, and accuracies in the range of 98–100%. ConclusionsThe initial results have shown that the EnhancedRBAC model can be effectively used to manage information access in the combined context of team collaboration and workflow for coordination of clinical education programs. Future research is required to perform longitudinal evaluation studies and to assess the effectiveness of EnhancedRBAC in other applications.

Psychiatrist Focuses on Populations in Health Delivery Services

Psychiatrist Focuses on Populations in Health Delivery Services

Opportunities and Responsibilities for the Academy in the Medical Home

Opportunities and Responsibilities for the Academy in the Medical Home

Report of the AACP Task Force on Patient-Centered Medical Homes and Accountable Care Organizations

TASK FORCE CHARGES A task force was convened by the American Association of Colleges of Pharmacy (AACP) to provide rationale for academic pharmacy engagement with organizations/ institutions providing new models of team-based patient care designed to improve patient access, care quality, and affordable care. Descriptions of new care models, such as patient centered medical homes (PCMHs) and accountable care organizations (ACO), were included as well as descriptions of existing partnerships with academic pharmacy. Specifically, this task force was charged with: 1. Providing a rationale for colleges/schools of pharmacy to engage in PCMHs and ACOs that includes a list of recommended articles and sites that could help members become informed about such organizations, corresponding professional association, regulatory bodies and government agencies. 2. Describing model partnerships of colleges of pharmacy with PCMHs and ACOs. 3. Disseminating information gathered above in a form of a white paper as a call to arms for the pharmacy academy. BACKGROUND The Patient-Centered Medical Home (PCMH) The medical home model holds promise as a way to improve health care in the United States by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place, but as a model of the organization of primary care that delivers the core functions of primary health care. The Medical Home encompasses six functions and attributes: 1. Comprehensive Care. The PCMH is accountable for meeting the large majority of patient physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include multiple providers, including physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. Although some medical home practices may physically bring together large and diverse teams of care providers to meet the needs of their patients, others, particularly smaller practices, will build virtual teams linking patients to providers and services within specific communities. 2. Patient-Centered. The PCMH provides primary health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient's unique needs, culture, values, and preferences. The medical home practice actively supports patient education and self care management based on their desired level. Recognizing that patients and families are core members of the care team, medical home practices ensure that they are fully informed partners in establishing and participating in their own care plans. 3. Coordinated Care. The PCMH coordinates care across all aspects of the health care system. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and other members of the care team. 4. Accessible Services. The PCMH delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care. The medical home practice is responsive to patients' preferences regarding access. (1) 5. Quality and Safety. The PCMH demonstrates a commitment to quality improvement by ongoing engagement in activities such as utilizing evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and their families, engaging in performance measurement and improvement, measuring and responding to patient experiences and satisfaction, and practicing population-based health management. …

Developing collaborative relationships between pharmacists and other health professionals

More than 40 years ago, the idea for what may be a landmark opportunity for pharmacy was introduced. In 1967, the American Academy of Pediatrics (AAP) first presented the concept of the medical home, with a focus on having a central location for a child's medical information. 1. American Academy of Pediatrics, Council on Pediatric Practice. Pediatric records and a “medical home.”Standards of child care.American Academy of Pediatrics Evanston, IL. 1967; : 77-79 Google Scholar In the 4 decades since that publication, the vision for the patient-centered medical home (PCMH) has evolved. In March 2007, the American Academy of Family Physicians, AAP, American College of Physicians, and American Osteopathic Association issued a joint statement on the principles of the PCMH. 2. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home.Accessed at, 15 March. 2011; http://www.medicalhomeinfo.org/joint%20Statement.pdf Google Scholar The guiding principles of patient care within the PCMH model include (1) a personal physician, (2) a physician-directed medical practice that provides team-based patient care, (3) whole-person orientation in which the physician focuses on all health care needs of the patient in collaboration with the health care team, (4) coordinated and integrated care, (5) quality and safety as hallmarks of care, (6) enhanced access to care, and (7) appropriate payment for value-added care. 2. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home.Accessed at, 15 March. 2011; http://www.medicalhomeinfo.org/joint%20Statement.pdf Google Scholar