Better Care Teams must have arrangements to provide care in all major specialties and the resources to provide a continuum of care from primary to acute to home or long-term care. Integrated delivery systems that encompass many components of team-based care would need to provide evidence that Better Care Teams are delivering the care. Many types of organizations qualifying for the team-based care requirement.

Primary care teams typically include a primary care physician, a nurse practitioner/physician assistant and/or a nurse, and a medical assistant at the core. (Naylor et al, 2010)[i]. Practices that focus on prevention will typically also have a pharmacist, clinical social workers/mental health professionals, nutritionist, and health educators as members of the team. Community health workers are increasingly becoming members of teams particularly in lower income communities where outreach services are the only way to engage with people unable to afford care.

Primary Care Medical Homes (PCMHs) sometimes called Patient-centered Medical Homes are one type of structure that would qualify. Other models or structures, such as ACO’s that participate in CMS bundle payment or other alternative payment models that require team-based care, could qualify as well.

Inpatient teams are multi-disciplinary and include nurses, physicians, advanced practitioners, pharmacists, social workers, and technicians. The team works off a single plan of care documented in a unified Electronic Health Record. These teams round together on the patient in the same room  debriefing afterward to develop a follow-up plan based on each team members role and responsibility. 

Hospital at home for example and virtual mental health programs that integrate with primary care practices would be other examples. The provider structure does not preclude the function though. The structure itself is not enough to qualify there must be clear evidence of team-based care processes or the organization would not be eligible to participate in a BCP.

Value of Team-based Care

Provider collaboration is critical to achieve highly coordinated care, as evidenced by an extensive and growing body of research on developing team members competencies, identifying the characteristics of effective teams and performance on cost and quality of outcomes. In many cases nurses are at the core of team based care.

Patients receiving care with poor teamwork are almost five times as likely to experience complications or death from surgery[ii]. Research has also found that found that patients receiving care from teams with higher levels of role clarity, mutual trust, and information exchange had lower levels of postoperative pain, higher post-operative functioning, and shorter lengths of stay (Gittell et al, 2000)[iii].

A recent meta-analysis review of 31 studies of teams found statistically significant “medium-size effects” on performance across multiple tasks including postoperative complications, and bloodstream infections ( Schmutz et al, 2019)[iv].

In primary care and outpatient care, there is evidence that teams that were more patient centered and that had “champions” were associated with making more changes and more in-depth changes to improve chronic illness care. ( Shortell et al, 2004).

Recent evidence on patient-centered medical homes that emphasized team-based care found that they saved Medicaid $214.10 per month for HIV patients with diabetes COPD, asthma, congestive heart failure or behavioral disorders (Cotton, 2018)[v] and a recent RAND study found that NCQA-qualified health centers using team-based care had better quality of care for diabetic patients and reductions in hospitalization and cost than non-NCQA PCMHs[vi].

A recent study of 250 primary care practices found that teams provided better care and outcomes than solo providers for patient with diabetes hyperlipidemia, and hypertension (Pany et al, 2021)[vii].

The VA, working on annual, pre-determined health budgets have increasingly used team-based care models to achieve better care. Leading health care organizations such as Atrius in Massachusetts, and Bellin in Green Bay, Wisconsin, are developing innovative new care models based on team care. For example, Bellin’s advanced team-based care model resulted in a 40 percent increase in age-appropriate screening and a five percent increase in quality metrics that were already high.

Criteria for Qualification

We propose that to qualify as a BCP available as part of the public option, a health plan will need to contract with Better Care Teams that provide care that is Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable, as defined by the National Academy of Medicine. We propose the following criteria to qualificy as a Better Care Team:

1. the team employs clinicians working with patients and their families to make care decisions together (Patient centered)
2. the team has the resources and capacity to provide or arrange for all needed care (Comprehensiveness)
3. the team actively coordinates the patients’ care across providers and sites (Continuity of care)
4. the team assumes responsibility for health outcomes and the cost of care (Accountability)
5. every team member is allowed to use their competencies and practice at the top of their license (Team-based care)
6. the team has access to point of care data on performance and has the systems and training to continuously improve care. (Data-driven continuous improvement)
7. the team assures that patients always have ready access to their claims and electronic health record data (patient centered)
8. the team can identify high-risk patients requiring special care needs (patient centered)
9. the team has access to appropriate resources to address patients’ behavioral and social needs (comprehensiveness)

Each BCP would need to have a process for measuring whether all these criteria are being met by each provider organization with which the BETTER CARE PLAN has a contract.

Quality/Patient Safety: Management, Measurement & Reporting

The BETTER CARE PLAN is designed to deliver measurably better quality of care through measuring and reporting outcomes and incentivizing better results. There is much room for improvement over current practice.  Hospital and health plan death rates, for example, have been shown to vary by as much as 3 to 1 depending upon the health plan or hospital patients choose.

Better Care Teams will be required to provide, on a timely basis, accurate, accessible, and comparable information on cost, risk-adjusted outcomes, and other measures of quality of care and consumer satisfaction so that participants can make informed choices. All Better Care Teams will be required to submit risk adjusted quality and cost data to a recognized public reporting entity.

A national quality data base will be established by the federal government through the Center for Medicare and Medicaid Services (CMS) for states that do not already have public reporting entities. Consideration should be given to creating a companion National Patient Safety Authority (NPSA) modeled after the National Transportation Safety Board (NTSB). The NSPA would be a repository for reporting of medical error data, analysis including use of artificial intelligence algorithms, and making recommendations complimenting the work of the Joint Commission, the Agency for Health Research and Quality, and related quality and patient safety groups.

Outcomes such as risk adjusted mortality and morbidity, medical errors,  and patient reported outcomes (PROs) will need to be reported for all conditions. Cleveland Clinic Orthopedics, for example, requires patients to fill out a PRO validated joint specific survey of 50 questions prior to surgery. Following the procedure surgeons document disease severity, accurate diagnosis, major risk factors for outcomes, and type of implant etc. One year after the procedure the patient fills out the same survey as before the procedure. PROs for other conditions such as breast cancer treatment (ref. Kaplan) are emerging and should be integrated into the public reporting process.

States that have public reporting such as Wisconsin, Washington and Massachusetts can use a delegated model of reporting in which providers report to the state entity. Quality and safety measures should be displayed so consumers can easily understand the report. Reports should include whether the Better Care Teams are improving or not over time.

The National Quality Forum (NQF) has developed many measures of health care quality but there is need for more relevant outcome measures. The majority of measures the NQF has endorsed relate to compliance with processes that are known to be important for quality care delivery. National Committee of Quality Assurance (NCQA) reports similar compliance measures for health plans. The BCP will move from measuring compliance to measuring outcomes of care.

Continuous Quality Improvement

Building a robust system of continuous improvement involving front line workers who identify and solve  problems quickly at the point of care is  paramount for success. The value creators in healthcare are the nurses, technicians, doctors, and others who provide care or support care delivery. The Better Care Teams will have more say in how clinical processes are designed and work. This means administrators will be relinquishing control to the people doing the work. At UMass Memorial in Worcester Mass. caregivers have implemented over 100,000 ideas generated by staff in the last five years. A management system focused on improvement has been shown to deliver better patient satisfaction, reduced 30-day readmission rates, lower rates of inappropriate imaging, in other words better value. (Shortell 2021)[viii]. There are different methods of building a management system but almost 70% of hospital system in the U.S. are applying lean, lean plus six sigma, or robust continuous improvement as a way to deliver better care. An organization supporting Better Care Teams will need to an enterprise-wide organizational excellence and continuous improvement approach.

Implementing an electronic health record (EHR) is not enough to qualify. The mistake healthcare leaders have made is making bad care processes electronic with the EHR rather than creating new and better processes that are then supported by the  EHR software. Better Care Teams are well equipped to understand the problems in existing care processes. They need to be given the opportunity to redesign new ones. The combination of better processes with the sophisticated software of the EHR can lead to much better care at lower cost.

Results

The purpose of the Better Care Plan quality and safety reporting and alternative payment models is to achieve better results for patients. We will know this by measuring PROs and by monitoring clinical outcomes and making that information available to the public using meaningful, understandable metrics. BCP-NGs will be required to report clinical and POR results and be graded on them. The information gathered on Better Care Teams will allow for understanding gaps and help direct efforts at closing those gaps in care. We believe the combination of Better care Plans based on a Medicare Advantage format that incentivize Better Care Teams to deliver care that is measured better and less costly and is publicly reported will transform U.S. healthcare system. 

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[i]     Naylor MD, Coburn TD, Kurtzman ET et al., Inter-professional Team-Based Primary Care for chronically Ill Adults: State of the Science. 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.

[ii]     Mazzocco K, Pettiti DB, Fong KT et al. Surgical Team Behaviors and Patient Outcomes. American Journal of Surgery, 197, 678-685. 10.1016/j.amjsurg.2008.03.002 ( PubMed:18789425)

[iii]    Gittell JH, Fairfield KM, Bierbaum B et al. Impact of Relational Coordination on Quality of Care, Post-Operative Pain and Functioning and Length of Stay: A Nine Hospital Study of Surgical Patients. Medical Care, 38, 2000:807-819 (PubMed: 10929993).

[iv]    Schmutz JB, Meier LL, and Manser T How Effective is Teamwork Really? The Relationship Between Teamwork and Performance in Healthcare Teams: A Systematic Review and Meta-Analysis. BMJ Open, 2019. DOI:10.1136/bmjopen-2018-028280

[v]    Cotton P. Patient-Centered Medical Home Evidence Increases with Time. Health Affairs Blog. September 10, 2018 DOI: 10.1377/hblog20180905.807827.

[vi]    Van Houten  CH, Hastings SN, and Colon-Emeric C. A Path to High Quality Team-Based Care for People with Serious Illness. Health Affairs, June 2019, 38(6): 934-940.

[vii]   Pany MJ, Chen L, Sheridan B, and Huckman RS. Provider Teams Outperform Solo Providers in Managing Chronic Diseases and Could Improve the Value of Care. Health Affairs 40, 3(2021):435-444.

[viii]   Shortell SM, Marsteller JA. Lin M et al. The role of Perceived Team effectiveness in Improving Chronic Illness Care. Medical Care, November 2004, 42(11):1040-1048.