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.
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.
- 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
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
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
- Team-Based Care Toolkit (Cambridge Health Alliance)
- CDC Best Practice Guide for Cardiovascular Disease
- Implementing Team-Based Care: Collaboration In Practice
- Core Principles and Values of Team-Based Care
- Creating a Patient-Centered Primary Care Team
- Diabetes Toolkit Resource Guide
- Patients and Health Care Teams Forging Effective Partnerships
- Team-Based Care to Improve Blood Pressure Control
- CCHN & CHAMPS Team-Based Care Webinar Series
- AMA Steps Forward: Implementing Team-Based Care
- Paying for Team-Based Care
- Methods and Resources for Engaging Pharmacy Partners
- Advancing Team-Based Care Through Collaborative Practice Agreements: A Resource and Implementation Guide for Adding Pharmacists to the Care Team
- Using the Pharmacists’ Patient Care Process to Manage High Blood Pressure
- Creating Community-Clinical Linkages Between Community Pharmacists and Physicians
- CDC Division for Heart Disease and Stroke Prevention: Pharmacy Guides
Primary Care Teams
- The MacColl Center for Health Care Innovation
- AHRQ’s Team STEPPS for Primary Care
- The Safety Net Medical Home Initiative
- PCMH Continuous and Team-Based Health Relationships
- What is a Patient-Centered Medical Home Infographic (Patient-Centered Primary Care Collaborative)
- Patient-Centered Specialty Practice (PCSP) Recognition
- AHRQ PCMH Resource Center
- Defining the Medical Home (Patient-Centered Primary Care Collaborative)
- Medicaid.gov Health Homes
- Medicaid.gov Guide to Medicaid Health Home Design & Implementation
- Medicaid.gov Health Home Frequently Asked Questions
- Flowsheet for Health Homes
- Map of CVD Rates, PCMH, and Health Homes in South Dakota
- Health Home Clinics with addresses
- SD DSS Health Homes
- SD Health Home Dashboard
- SD Health Home Program Brochure
Other forms of Team-Based Care
- Federally Qualified Health Center Booklet (CMS)
- Institute for Healthcare Improvement: Cooperative Health Care Clinics: A Group Approach to Individual Care
- Warm Handoffs: AHRQ Implementation Quick Start Guide
- The Community HealthCare Association of the Dakotas (CHAD)
National Case Studies
- 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
- 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
- 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
- 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
- Community Preventive Services Task Force. Team-based care to improve blood pressure control. American Journal of Preventive Medicine. 2014; 47(1):100-102.
- Task Force on Collaborative Practice. Collaboration in practice: Implementing team-based care. The American College of Obstetricians and Gynecologists. 2016.
- 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
- 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
- Improving Primary Care. The primary care team guide. 2018 http://www.improvingprimarycare.org/
- 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/
- Patient-Centered Primary Care Collaborative. The patient-centered medical home: Frequently Asked Questions (FAQ). 2018. https://www.pcpcc.org/about/medical-home/faq
- NCQA. Patient-centered medical homes fact sheet. 2017. https://thepcc.org/content/patient-centered-medical-home-frequently-asked-questions-faq
- NCQA. PCMH eligibility. 2018. https://www.ncqa.org/programs/health-care-providers-practices/certified-content-expert-cce/maintaining-certification/criteria-cce/
- Qualis Health. Practice Transformation 101. http://practicetransformation.qualishealth.org/resources/practice-transformation-101
- U.S. Department of Veterans Affairs. Patient care services: patient-aligned care team (PACT). 2018. https://www.patientcare.va.gov/primarycare/PACT.asp
- U.S. Department of Veterans Affairs. Patient care services: Coordinated care- PACT. 2018. https://www.patientcare.va.gov/primarycare/pact/Coordination.asp
- 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
- U.S. Department of Veterans Affairs. Patient care services: Primary care. 2017. https://www.patientcare.va.gov/primarycare/index.asp
- Sioux Falls VA Health Care. PACT: Patient-aligned health care. 2018.
- 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
- DSS. Frequently asked questions. 2015. https://dss.sd.gov/medicaid/generalinfo/faq.aspx#healthhomes
- 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
- Council for Exceptional Children. Behaviors disorders: Definitions, Characteristics, & Related Information. https://debh.exceptionalchildren.org/behavior-disorders-definitions-characteristics-related-information
- Rural Health Information Hub. Federally qualified health centers (FQHCs). 2018. https://www.ruralhealthinfo.org/topics/federally-qualified-health-centers
- Health Resources & Services Administration. Federally qualified health centers. 2018. https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html
- 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
- 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.
- 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