Dr. Tina Bettin DNP, MSN, RN, FNP-BC, APNP

OBJECTIVES Describe concepts related to team-based care & give

examples of the concepts in practice.

Discuss the impact of team-based care on quality outcomes.

Recognize ways to keep team-based care patient-centered

Apply this information to professional practice

“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.” Naylor MD, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: State of the Science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. Philadelphia, PA; March 24-25, 2010.

THEDACARE’S PRINCIPLES Mission

ThedaCare’s mission is to improve the health of our communities.

Vision Our vision is to always set and deliver the highest standard of

health care performance in measurable and visible ways so our customers are confident they are making the right decision in choosing us.

Values Our values are the internal compasses that guide our day-to-

day decisions. They are the glue that holds the organization together.

NEW LONDON CALL GROUP

POPULATION SERVED Rural population

Portion is in a federal designated Health Professional Shortage Area (HPSA)

Providers serve as PCPs for 13,000 individuals

98% Caucasian

89% HS diploma ( than WI average)

16% Bachelor’s or higher ( than WI average)

POPULATION SERVED Median Income $48,000

19% Persons age 65 & older (WI average 14%)

11.2% families below poverty level

17% of children considered in poverty

42% children eligible for free/reduced lunch

27% of children in single parent homes

24% binge drinking

32% BMI above 30

THE BEGINNING Initially 1 MD & 1 NP in 1995

Culture was started—patient-focused; on-call & hospital responsibilities for NP

2000-2001 expanded; 3 MDs & 3 NPs (1 male); worked in teams of 2

2002 expanded; 5 MDs & 3 NPs

Interviewing included questions on team concepts, interactions with NPs & PAs; change concepts

CLINICAL TEAM MAKE UP Providers: 7 MDs, 6 APRNs & 3 PAs-all but 1 PCPs

Manager & 2 supervisors

Practice Associates

Patient Service Representatives

Triage (11 nurses; 5.8 FTEs)

Cell Leads

Disease Management (1 PT RN) Medical records, coding, laboratory & radiology

TEAMS New London Business Pod Team

NL, Manawa & Weyauwega

Teams within the team

Providers have 1-2 practice associates

Hallway placement or outlying clinic placement

2 providers per hallway with 3 practice associates 1 provider w/2 & 1 provider w/1

1 Cell lead per 2 hallways

Floating Patient Service Representatives (PSRs)

PERSONAL VALUES OF TEAM MEMBERS Honesty-transparency; critical to improvement &

maintaining mutual trust

Discipline-seeking & sharing new ideas

Creativity-excited to tackle new & emerging problems

Humility-recognize differences in training; individuals are human & will make mistakes

Curiosity-reflection; continuous improvement Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine; October 2012. www.iom.edu

THEDACARE VALUES ThedaCare values are:

Focus on the customer – their needs are our top priority

Have a thirst for learning– continuously seek out ways to do our work better

Be courageous– challenge each other’s ideas to come up with the best thinking and solutions

Love your work– let your passion show every day

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Shared goals work to establish shared

goals that reflect patient & family priorities.

Mission statement

ThedaCare’s mission is to improve the health of our communities.

“Lori” developed in 2010

Transparency of goals with staff

Goal directed problem list

Patient as part of LEAN team

Shared Goals-continued Across the board, just as they preach, ThedaCare is

patient-centered. Lori (the patient) is a word that's heard and seen all over the hospital. Lori is their patient and their true north. She has a face and a name and is a real person. On each floor, on each board there is a picture of Lori. Every project, mission, and objective actually connects back to Lori. Lori is why ThedaCare wants to build healthy communities

McGuinness D, More Evidence That ThedaCare Rocks. The Lean Post. October 9, 2013

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Clear roles Clear expectations of team

members functions, responsibilities & accountabilities thereby optimizing team’s efficiency & take advantage of divisions of labor

All providers as paneled PCPs

Rooming standards for practice associates

All practice associates certified

MA schedule

Scheduling PSR

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Mutual Trust Earn each other’s trust,

create a shared interest in teammates & their protection resulting in shared achievement

3 practice associates working as a team

Call rotation

Outlying clinics coverage for providers & staff

Community Health Assessment Team (CHAT)

Rural Health Initiative

Mental health

Obesity

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Effective Communication Consistent channels for

transparent communication which are used by all team members

Daily huddles

Weekly provider meetings

Staff meetings

Leadership updates

Monthly CEO memos

Common calendars

Charter communications

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Measurable Processes & Outcomes Implements feedback

mechanisms to track & improve performance/outcomes

Monthly provider updates on quality data

Tracking boards

Annual metrics—target set by Senior leadership

“True North” metrics

Wisconsin Collaborative for Healthcare Quality (WCHQ)

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Adaptability Adjust strategies based on

environmental information & reallocation of resources

Altering course of team in response to changing conditions

Use of NP for hospitalist

Central Command

Providing care for patients in clinic when scheduled provider is in an urgent situation

LEAN

Changing reimbursement from production to quality

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Backup Behavior

Ability to anticipate other’s needs

Ability to shift workload among members to achieve balance

Refill protocol-triage

Protime protocol-protime nurse

Strep & urine protocols

MDs & APCs seen as equals

Procedure set up book

“Secret sauce” for time off

Collegiality among providers

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Team/collective Orientation Belief of team’s goals over

individual member’s goals

Health maintenance alerts addressed by all who contact patient

Patient treated like provider is PCP, even when not

Disease management RN

CHAT

Community service

Women’s Health Day

Mission of Hope

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Mutual performance monitoring Ability to develop common

understandings of team environment & apply appropriate task strategies in order to accurately monitor teammate performance

PDPs for staff

Provider reviews

Twice yearly provider/employee surveys

Skills check off list

Models for providers

Interactive Employee Education data base & electronic data base for performance (Halogen)

TEAM-BASED CARE CONCEPTS CONCEPT EXAMPLE

Team Leadership Ability to direct & coordinate

activities of team members

Assess performance of team

Assign tasks

Motivate

Establish positive atmosphere

Lead projects—A-3; value streams; PDSA; SBAR

Monitor/track outcomes

Thank you cards

Challenges-w/in business pods and between pods

Volunteer opportunities

PATIENT OUTCOMES ThedaCare is repeat top performer in WCHQ

New London business pod is usually in the top 2 performers within system annually

September 2014-CMS reported Bellin-ThedaCare HealthCare Partners were ranked #1 out of the 23 Pioneer Affordable Care Organizations (ACOs); quality score 94.11; lowest cost; measured on 33 factors

TEAM SATISFACTION Overall very good

Bi-annual reviews over 3.0 on 4 point scale by both staff & providers

Sought after clinical rotation site for future providers and staff

Advancement of individuals w/in organization

Workload distributed

Staff turnover is 3%, less than state & national average

TEAM SATISFACTION Public recognition helps

ACO Pioneer-top performer

Top 100 Most Wired Healthcare Organizations for over 10 years

National Rural Health Association-TCMC-NL Top 20 CAH in country in area of financial stability x 2

VHA Sustainability Excellence Award –efforts to recycle single-use plastics

CHALLENGES Maintaining culture as clinic expands

Complacency—minimal; team challenges help; staff turnover <3% (less than state & national average)

Changing roles with ACA

Change itself

Payment still mostly production based

CELEBRATIONS Team challenges

Breakfast served by the providers

T-shirt days

Picnics

Team lunches/dinners

Celebration/Appreciation cards

ThedaCare Follies

Fall Fest for Families

COMMUNITY GARDENS

www.youtube.com/watch?v=9bcMpdv3Fdc

Questions?

REFERENCES

*American Hospital Association. Workforce roles in a redesigned primary care model. Executive summary. September 2011.

*Bendix J. Building a team-based medical practice. Medical Economics. September 10, 2013. http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/accountable (accessed on May 9, 2015)

*Bettin, T, Personal Experiences

*Gruman J, What does team-based care mean for patients? Center for Advancing Health. January 8, 2014. http://www.cfah.org/blog/2013/what-does-team-based care mean for patients (accessed May 9, 2015)

*Hupke C, Team-based care: Optimizing primary care for patients & providers. Safety first blog, IHI. http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx? (accessed May 8, 2015).

*Institute of Medicine (US); Olsen LA, Saunders RS, McGinnis JM, editors. Patients charting the course: Citizen engagement & the learning health system: Workshop summary. Washington DC: National Academies Press; 2011.

REFERENCES

*King H, Battles J, Baker D, Alonso A, Salas E, Webster J, Toomey L, & Salisbury M, TeamSTEPPS: Team strategies & tools to enhance performance & patient safety. http://www.ncbi.nlm.nih.gov/books/NBK43686/ (accessed May 9, 2015)

*McGuinness D, More Evidence That ThedaCare Rocks. The Lean Post. October 9, 2013.

*Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine; October 2012. www.iom.edu

*Naylor MD, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: State of the Science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. Philadelphia, PA; March 24-25, 2010.

*Patient-Centered Primary Care Collaborative. Team-based care: A critical element of primary care transformation. Population Health Management. February 2013.

REFERENCES

*Quinn T, Bringing a management model to healthcare: Team-based care. http://www.forbes.com/sites/groupthink/2014/12/09/bringing -a-management-model-to-healthcare (accessed May 9, 2015).

*Rodak S, 5 core principles of team-based healthcare. Becker’s Hospital Review. October 4, 2012. http://www.beckerhospitalreview.com/strategic-planning/5-core-principles-of-team-based-care (accessed May 8, 2015).

*Toussaint J, & Gerard R, On the mend. Cambridge, MA. Lean Enterprise Institute, 2010.

*Wynia MK, Von Kohom I, Mitchell PH. Challenges at the intersection of team-based & patient-centered healthcare. JAMA 2012; 308(13): 1327-8. (accessed May 8, 2015)