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Use of Care Teams in Patient-Centered Medical Homes

Adaptive Medical Partners | Healthcare News, Physician Recruiting

Use of Care Teams in Patient-Centered Medical Homes

Over the past decade or so, American health care practitioners and policymakers have explored ways to improve the quality of care for patients while lowering the costs of that care. The team-based, patient-centered model of health care delivery promises the potential for practice transformation and is increasingly being adopted by clinics, hospitals and primary care practices across the United States. Learn more about the patient-centered medical home and care teams within these delivery models.

Healthcare Team

What Is a Patient-Centered Medical Home?

The patient-centered medical home (PCMH) — also referred to as the primary care medical home, advanced primary care, and the health care home — is not a physical place. It is, instead, an approach to providing health care to patients. Definitions of the medical home vary, but one of the most widely accepted visions of the PCMH comes from the Agency for Healthcare Research and Quality (AHRQ), which identifies the following as required elements of the PCMH organization:

  • Patient-centered: The patient’s preferences and needs are respected by practitioners, and patients are provided the education and support that enable them to make decisions about, and participate in, their own care.
  • Comprehensive: The care team takes responsibility for the totality of a patient’s health, including physical and mental health care needs, from prevention and wellness to primary care, as well as acute and chronic care.
  • Coordinated: The PCMH coordinates the patient’s care beyond the practice, extending to the broader health care system to include specialty care, hospitals and supportive services.
  • Accessible: Patients’ access to services are enhanced and more extensive, allowing them to receive services with shorter waiting times, ensuring availability of after-hours care, and providing electronic or telephone access to the care team.
  • Committed to quality and safety: Clinicians use evidence-based practices and commit to ongoing quality improvement.

What Is a Care Team?

patient-centered care team refers to a group of personnel who identify as and work together as a team to provide care for individual patients. This team’s composition will vary across practices, and even within the same practice, depending on the particular needs of the patient at different points in time. Provider care teams typically include a range of clinical personnel, such as physicians, nurses, panel managers, nutritionists, pharmacists, medical assistants and social workers, as well as nonclinical staff, such as peer counselors and registration staff. The patient and caregivers are also essential members of the care team.

Different parts of the patient’s care is managed by different care team members based on the individuals’ qualifications. Staff are encouraged to work at their highest levels, performing work matched to their abilities.

Well-implemented team-based care as part of a primary care medical home can improve the efficiency and effectiveness of the care provided, as well as increase both patient and provider satisfaction levels. Additionally, this model has the potential to provide high-quality care that addresses the whole patient’s health through the inclusion of additional services such as patient education, behavioral health support and coordination of care beyond periodic appointments.

Assembling the Right Team

Bringing together the right roles does not necessarily create the right team. Positions are important, but even more so are the people in those positions. Effective teams require that members work well together; team members must be committed to the principles of team-based care, communicative, and able and willing to collaborate. Adaptive Medical Partners can help you find the right fit for your medical home.