Resources for Implementing Team-Based Care
As the healthcare delivery system moves from fee-for-service payments to value-based payment models and care itself becomes more complex, team-based care is becoming increasingly more important. Studies, such as one from the Institute of Medicine, have found that team-based care has a positive impact on patient outcomes, patient experience and the cost of treatment.
Collaboration between medical team members allows them to share knowledge and work toward a common goal of improved patient outcomes and patient experience, enabling them to better provide patient-centered care. Improved communication can decrease instances of misdiagnosis, overlap and redundancy for reduced healthcare costs. The team-based care approach looks critically at the source of a patient’s ailments, rather than simply focusing on symptoms, which can also eliminate ED visits, another savings benefit, especially for high-risk, high-need populations.
The Primary Care Development Corporation’s (PCDC) Performance Improvement team offers the Essentials of Care Management course, a two-day curriculum that focuses on the principles of care coordination, with a focus on two significant aspects that affect the populations served by PCDC providers: the social determinants of health and motivational interviewing.
Social Determinants of Health
The social determinants of health (SDOH) are critically important for the health providers PCDC serves to fulfill its singular mission: to bring culturally competent and high-quality care to underserved communities. Many health care system patients in underserved areas are affected by SDOH—food and housing insecurity, unreliable transportation access and education disparities—the complex, integrated, and overlapping social structures that make up SDOH.
The course highlights the many ways SDOH impacts not just quality of life, but health outcomes. That knowledge equips participants to be better prepared to understand the impact of SDOH and meet the needs of their patients.
PCDC’s High Impact Prevention (HIP) in Health Care program, which provides free capacity building and technical assistance to clinical healthcare settings to expand and improve the delivery of HIV prevention services, is also part of the Essentials of Care Management course. The customized training is designed to support healthcare providers and staff in increasing the number of patients who understand and use pre-exposure prophylaxis (PrEP) to prevent HIV.
The expertise and real-world experience of the PCDC staff, research, and state-of-the-science data are combined to deliver an effective training approach that helps patients commit to positive behavior changes. The PCDC trainers coach providers on how they can create a safe and empathetic environment that allows them to determine and examine patient barriers to PrEP use and to discuss realistic solutions.
Based on ground-level work led by PCDC with five New York State Health Homes, we have also authored a report entitled, “Delivering Team-Based Chronic Care Management: Overcoming the Barriers.” The report provides recommendations to support better healthcare, particularly for high-risk, high-need individuals to help other health centers make a difference for their patients.
Let us know how we can help you become one of the growing number of practices PCDC works with to build healthy, thriving communities through community investments, capacity-building, and policy initiatives.