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South Dakota Department of Health
South Dakota Department of Health

Heart Health

Team-Based Care Toolkit

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.

Health care has not always been seen as a “team sport.” However, as health care evolves and multiple clinicians now provide care to the same patient or family, the model for care is also shifting. Those clinicians must become a team, working together with the common aim of providing the best possible care.

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What are the Benefits?

Primary-care practices can achieve better care experiences, better population health, lower costs, and happier staff by creating more effective practice teams.

Advantages include:
  • Expanded access to care due to more hours of coverage and shorter wait times
  • More effective and efficient delivery of additional services essential to providing high-quality care, such as patient education, behavioral health, self-management support, and care coordination
  • Increased job satisfaction
  • An environment in which all medical and nonmedical professionals are encouraged to perform work that is matched to their abilities and scope of practice
  • Data-driven, continuous quality improvement through effective intra-team communication and problem-solving
  • Patients are more likely to get the care they need with the expertise of a variety of team members

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What are the Models?

Team-based care can take a few different forms, including the following potential models that offer varying benefits:

How to Get Started

Setting your system up for success when it comes to team-based care takes dedication to the core principles of this approach:

  • Putting the patient first
  • Building team culture
  • Empowering staff members
  • Encouraging critical thinking
  • Knowing your population

Get Started

Download Our Worksheet

 

Additional Resources

Introducing the South Dakota Team-Based Care Toolkit

This webinar showcases the new South Dakota Team-Based Care Toolkit and demonstrates in real-time how to access helpful, South-Dakota specific resources for team-based care.

Types of Team-Based Care

Curious about team-based care?  Whether you're interested in a particular model of team-based care or incorporating elements of team-based care into your practice, this webinar meets you where you are to help you take team-based care to the next level.

Patient and Provider Perspectives on Team-Based Care

This webinar features a panel of professionals who bring the experience of team-based care to life, including both the patients' and providers' perspectives. Team-based care's return on investment (ROI) is also discussed.

Realities of Team-Based Care in Rural South Dakota

What does team-based care look like in rural communities?  Hear from facilities making team-based care work amidst the challenges of serving rural and frontier communities.

General Team-Based Care

Communication

Patient Safety

Pharmacy

Primary Care Teams

PCMH

PACT

Health Homes

Other forms of Team-Based Care

National Case Studies

  1. Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, and I. Von Kohorn. 2012. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC. https://nam.edu/wp-content/uploads/2015/06/VSRT-Team-Based-Care-Principles-Values.pdf
  2. Okun, S, Schoenbaum S, Andrews D, et al. Patients and health care teams forging effective partnerships. Discussion Paper. Washington, DC: Institute of Medicine; 2014. https://www.accp.com/docs/positions/misc/PatientsForgingEffectivePartnerships - IOM discussion paper 2014.pdf
  3. Schottenfeld Lisa, Petersen Dana, Peikes Deborah, et al. Creating patient-centered team-based primary care. AHRQ. March 2016; 16-0002-EF. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/creating-patient-centered-team-based-primary-care-white-paper.pdf
  4. Okun Sally, Schoenbaum Stephen C., Andrews David, et al. Patient and health care teams forging effective partnerships. Discussion Paper, Institute of Medicine, Washington, DC. 2014. https://www.accp.com/docs/positions/misc/PatientsForgingEffectivePartnershipsIOM discussion paper 2014.pdf  
  5. Community Preventive Services Task Force. Team-based care to improve blood pressure control. American Journal of Preventive Medicine. 2014; 47(1):100-102.
  6. Task Force on Collaborative Practice. Collaboration in practice: Implementing team-based care. The American College of Obstetricians and Gynecologists. 2016.
  7. Donahue KE, Vu MB, Halladay JR, Miller C, Garcia BA, Cummings DM, et al. Patient and practice Perspectives on strategies for controlling blood pressure, North Carolina, 2010–2012. Prevention of Chronic Disease, 2014;11:130157 https://www.cdc.gov/pcd/issues/2014/13_0157.htm
  8. Community Preventive Services Task Force. Diabetes management: Team-based care for patients with type 2 diabetes. https://www.thecommunityguide.org/findings/diabetes-management-team-based-care-patients-type-2-diabetes
  9. Improving Primary Care. The primary care team guide. 2018 http://www.improvingprimarycare.org/
  10. Dingley Catherine, Daughtery Kay, Derieg Mary K., Persing Rebecca. Improving patient safety through provider communication strategy enhancements. Advances in Patient Safety: New Directions and Alternative Approaches, 2008; 3. https://www.ncbi.nlm.nih.gov/books/NBK43663/
  11. Patient-Centered Primary Care Collaborative. The patient-centered medical home: Frequently Asked Questions (FAQ). 2018. https://www.pcpcc.org/about/medical-home/faq
  12. NCQA. Patient-centered medical homes fact sheet. 2017. https://thepcc.org/content/patient-centered-medical-home-frequently-asked-questions-faq 
  13. NCQA. PCMH eligibility. 2018. https://www.ncqa.org/programs/health-care-providers-practices/certified-content-expert-cce/maintaining-certification/criteria-cce/ 
  14. Qualis Health. Practice Transformation 101. http://practicetransformation.qualishealth.org/resources/practice-transformation-101
  15. U.S. Department of Veterans Affairs. Patient care services: patient-aligned care team (PACT). 2018. https://www.patientcare.va.gov/primarycare/PACT.asp
  16. U.S. Department of Veterans Affairs. Patient care services: Coordinated care- PACT. 2018. https://www.patientcare.va.gov/primarycare/pact/Coordination.asp
  17. U.S. Department of Veterans Affairs: Patient care services: PACT- Team-based care. 20.18. https://www.patientcare.va.gov/primarycare/pact/Team-Based.asp
  18. U.S. Department of Veterans Affairs. Patient care services: Primary care. 2017. https://www.patientcare.va.gov/primarycare/index.asp
  19. Sioux Falls VA Health Care. PACT: Patient-aligned health care. 2018.
  20. Medicaid. Health homes (section 2703) frequently asked questions. 2012. https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-home-information-resource-center/design-and-implementation/index.html
  21. DSS. Frequently asked questions. 2015. https://dss.sd.gov/medicaid/generalinfo/faq.aspx#healthhomes
  22. Medicaid. Health homes (1945 of SSA Section 2703 of ACA) frequently asked questions series II. 2015. https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-home-information-resource-center/downloads/health-homes-section-2703-faq.pdf 
  23. Council for Exceptional Children. Behaviors disorders: Definitions, Characteristics, & Related Information. https://debh.exceptionalchildren.org/behavior-disorders-definitions-characteristics-related-information
  24. Rural Health Information Hub. Federally qualified health centers (FQHCs). 2018. https://www.ruralhealthinfo.org/topics/federally-qualified-health-centers
  25. Health Resources & Services Administration. Federally qualified health centers. 2018. https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html
  26. Scott, J., Gade, G., McKenzie, M., & Venohr, I. Cooperative health care clinics: A group approach to individual care. Geriatrics. 1998;53(5), 68-70, 76. https://www.ncbi.nlm.nih.gov/pubmed/9597981
  27. Elder C. Application of the Cooperative Health Care Clinic Model for Delivery of Complementary/Alternative Medicine (CAM) Care. The Permanente Journal. 2003;7(1):55-60.
  28. Agency for Healthcare Research and Quality. Implementation quick start guide warm handoff. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-qsg-letter.pdf