Team-based care is a strategy implemented at the health system level that aims to enhance patient care by having health professionals from different disciplines work collaboratively with the patient and the patient’s primary care provider.

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.

1. Implement 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.
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2. 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.

3. 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.

4. Standardized Triage and Checkout – Standardize both the triage and checkout process to ensure consistent, quality care for every patient, every time.