• Total Shared Savings Revenue by Organization- $1.5 Million Annual
  • Total Care Management Fee Revenue by Organization - $300K Annual
  • Increased Hypertension Control to 80%
  • Increased Diabetes Control to 65%
  • Decreased ER Utilization 25%
  • Chronic Care Management Enrollment Average 40% of total Medicare Lives
  • Chronic Care Management Revenue by Organization- $50K monthly
Process Improvement

Team Based Care

Working 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.

Team Based Care

What is Team Based Care?

Team-based care is defined by the National Academy of Medicine as “…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.” This model puts each patient at the center of a team of caregivers, aligning every resource available to meet the needs of the patient.

What are the Core Concepts of Team Based Care?

  1. Start on Time – This will minimize the stress on the core and Extended Care team, and respects the time taken by the patient to come in for the visit.
  2. Daily Huddles – Brief daily in-person check-ins of the clinic’s core team to review the day’s schedule, identify and anticipate patient needs, and build team culture.
  3. Warm Handoffs – Verbal communication about the patient between team members, often in the presence of the patient. This enhances patient engagement and satisfaction while demonstrating effective communication between team members.
  4. Expanded Standard Rooming Processes – This allows medical assistants to address as many visit-needs before the provider enters the room, such as: behavioral health screenings, medication reconciliation, and choosing an order set.
  5. Use of Extended Care Resources – Case Managers, Diabetes Educators, Patient Care Coordinators, among others, play a key role in helping to care for our highest risk and most complex patients. This includes referral management, the tracking of patient referrals throughout the care continuum to ensure timely care, support patient needs, and streamline communication among providers.
  6. Regular Care Team Meetings – This allows for communication between all team members involved in the care of complex or high-risk patients, as well as focused discussion on the care gaps of all patients, resulting in coordinated, effective care.
  7. Standardized Triage and Checkout – Standardize both the triage and checkout process to ensure consistent, quality care for every patient, every time.

How will we know if Team Based Care is successful?

  • Improving quality measures
  • Increasing staff satisfaction and decreasing staff turnover
  • Boosting clinic productivity, collaboration, and a sense of “teamwork”
  • Increasing patient volume and satisfaction
Success from Team Based Care