Pri-Med East 2013

Team-Based Care Requires Collaboration, Communication, and Respect for the Contributions of all Team Members

Despite the promise it holds for reducing errors and improving quality of care, interprofessional collaboration among physicians, nurses, physician assistants, and other health care providers is not the norm. One way to increase interprofessional collaboration is to educate clinicians together (especially so that they have a greater understanding of the roles played by each team member) and retrain providers to work together as part of a cohesive team.
During their presentation on effective team-based care at the 2013 Pri-Med East Conference and Exhibition, Karen Carlson, MD, Massachusetts General Hospital, General Internal Medicine, and Ellen Long-Middleton, PhD, RN, FNP, Massachusetts General Hospital, Institute of Health Professions, defined interprofessional collaboration in the health care setting as “Utilization of both the individual and collective skills and experience of team members, allowing them to function more effectively and deliver a higher level of services than each would working alone.”
They discussed the great contrast between collaborative and conventional medical care, noting that conventional care is an authoritarian model in which the physician is the dominant decision maker and care is fragmented and episodic and delivered largely by autonomous physicians. In the collaborative model, care is patient-centered, continuous, and coordinated in a team-based atmosphere with all members sharing responsibility for outcomes.
With conventional care, patients are treated during short, one-size-fits-all visits that are reactive and focused on illness. Reimbursement is based on volume (ie, fee-for-service), and communication between providers and care settings is inconsistent. Under the collaborative care approach, patients receive preventive, health-and-outcomes-focused care via individualized visits that can include a variety of communications strategies and platforms. Reimbursement is based on value (incorporating outcomes, quality, and cost), and communication amongst and between providers is imperative.
Several studies show that poor interprofessional collaboration negatively affects the delivery of health services and patient care, while practice-based interprofessional interventions can improve health care processes and outcomes (Zwarenstein et al. Cochrane Collaboration. 2009).
Collaborative care necessarily requires a more prominent role for nurses, nurse practitioners, and physician assistants in decision making and delivery of care. Despite the resistance to this by many physicians, who cite concerns over inadequate training and diagnostic expertise on the part of non-MDs, when it comes to nurse management of chronic conditions, studies have found no significant differences between physicians and NPs in health outcomes for patients, process of care, resource utilization, and cost. When nurses are the first contact for urgent care the health outcomes are similar to those seen in physician-provided care, and patient satisfaction is higher (Laurant et al. Cochrane Collaboration. 2009). In one randomized trial of NPs and physicians in New York City, researchers found comparable outcomes for health status, physiologic measures, and service utilization (Mundinger 2000). This was confirmed two years later in a follow up study (Lenz 2004).
Despite this evidence showing the effectiveness of NPs and others in providing care, several barriers still exist to expanding their roles and thus implementing collaborative care on a wider scale. One such barrier to interprofessional collaboration is the inability of members of the health care team to practice to the full scope of their expertise due to various state laws limiting the scope of practice and prescribing authority of NPs and PAs (whose license often ties them to a supervising physician). Other barriers are financial in nature (Medicare reimburses NP/PA service at 85% of the physician schedule unless the care is “incident to” a physician’s professional service) or tied to professional tensions between providers (stemming largely from the aforementioned physician concerns over quality of care and loss of control).
Although some professional physician’s groups still support direct supervision of NPs and PAs by physicians (including the AMA, AOA, AAP, and AAFP), others support broadening the NP scope of practice (including the IOM, AAMC, AACOM, NCSBN, AARP, and Macy Foundation).
A statement from the American College of Physicians in 2009 saying that “the College recognizes the important role nurse practitioners play in meeting current and growing demand for care,” also came out in support of collaborative practice, proclaiming that “Whenever possible, needs and preferences of every patient should be met by the health care professional with the most appropriate skills and training to provide the necessary care.” A 2003 report from the Institute of Medicine affirms these ideas, stating that “all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and quality.”
So, how to implement a team-based, collaborative approach to care? The presenters outlined several shared values of high-functioning health teams (including honesty, creativity, discipline, humility, and curiosity), along with several principles to guide team-based care (clearly defined roles for all team members, mutual trust in team members’ skills and expertise, effective communication at all stages of care, shared treatment goals, and the use of measurable processes and outcomes). It is also important that all members are committed to building a collective identity as a team.
The bias toward traditional care models is slowly eroding, with greater numbers of primary care providers (especially physicians) becoming aware of the advantages to a more collaborative approach to care that invites greater contributions from NPs, PAs, and other providers. To further this development, educators, payers, and other stakeholders at all levels will need to push for greater interprofessional training and improved reimbursement models that reward collaboration.

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