Unlocking the Power of Team-Based Care for Better Patient Outcomes

The African proverb it takes a village to raise a child has some parallels in health care. It takes an integrated and engaged team to provide people with whole-person care, which is the patient-centered coordination of health, behavioral health, and social services with the goals of improved health outcomes and more efficient and effective use of resources. Team-based care leads to whole-person care. More primary care practices are adopting the team-based care model to achieve the quintuple aim: equity; improved health outcomes; happier patients; higher provider and staff satisfaction; and lower costs. Since 2015, JSI has led work with practices serving low-income populations throughout Colorado to implement team-based care.

Our Approach to Team-Based Care

We start by working with practices on the foundational pillars: ensuring each patient has an assigned provider and care team with clearly defined roles and tasks; establishing quality improvement processes; and, providing strong leadership support. Next, we assess how these components fit into existing clinical workflows, including behavioral health integration, care management, medication management, and addressing social needs.

“Team-based care supports stronger primary care by fostering trust, quality, integration, communication, and coordination among the clinical team and with patients and their families,” said JSI Colorado Director Alexia Eslan.

JSI’s team-based approach is exemplified by the Team-Based Care Initiative (TBCI) launched by the Colorado Health Foundation in 2015. For the next four years, JSI worked with the Center for Accelerating Care Transformation at Kaiser Permanente Washington Health Research Institute, the Colorado Community Health Network, and subject matter experts (SME) to provide technical assistance (TA) to 19 primary care practices in Colorado. JSI’s collaboration with academia, community organizations, and experts in the non-profit clinical space fostered a unique partnership that strengthened primary care for people living in underserved and underrepresented communities.

The Team-Based Care Initiative

The TBCI TA team guided primary care practices through their transformation to a team-based care model. The team focused on establishing and sustaining the foundational pillars and culture for the model; ensuring high-quality core team performance of prevention and chronic illness; enhancing patient-centered care; building an expanded care team to enhance care for subpopulations, and connect to the community; and, integrating behavioral and social health capacity in primary care through tailored coaching and subject matter expertise, peer-learning, leadership development and resource sharing of standards of practices.

We also looked at the physical space at the practices and how the teams interacted on a regular basis. When the care team is actually sitting together there’s so much more communication about what’s happening. Patient care coordination improves quite radically,” said Eslan.

Providers and Patients Reported Success

Mathematica, a research and data analytics firm, worked alongside the TA team throughout the initiative and conducted an evaluation of the initiative. The evaluation found that implementing team-based care in the 19 Colorado practices had a notable impact on patient care and staff and provider morale.

“From the patient experience side, we heard a lot of positives. Patients shared they felt they had a team that takes care of them, understands them, and communicates with each other so everyone involved know what the patient’s needs are. Patients expressed not having to repeat themselves as a huge plus and they felt well taken care of. From the clinical team side, we heard they really liked working as a team and understanding how they can support each other, connect better, and coordinate care more efficiently,” said Eslan.

The participating health care practices continue to use many of the TBCI evaluation tools, such as the Primary Care Team Guide Assessment, to measure team-based care improvement. The TBCI TA team also used some of these tools to measure their own “teamness,” including the Staff Team Survey.

“Alongside our work with the practices, we were working on ourselves as a team and ensuring that we were using the same principles of team-based care within our TA team. That was very helpful because along the way we were learning and honing our own strengths and tailoring our TA approach in order to center the practices and their needs. We had a great team, everyone connected well, we had fun and everyone cared about having a positive impact,” said Eslan.

Next Steps

JSI continues to work with the Colorado Health Foundation on a second iteration of the TBCI called Advancing Team-Based Care, launched in 2020, with 16 primary care organizations across Colorado. This initiative expands on the foundations of team-based care, adding health equity and financial sustainability as pillars of the TA provided.

“We’ve taken lessons learned from TBCI and working with the researchers in academia to create a new initiative that continues to spread team-based care throughout the state, strengthening primary care to better serve low-income Coloradans. Lessons learned are being shared with other health care transformation initiatives that JSI leads across the country,” said Eslan.

Eslan along with other researchers describe the TBCI process in Colorado in an article published in the journal Project Muse.