Learning Collaboratives to Advance Team-Based Care: Why You Should Care

INTRODUCTION

Health care optimization is an integral and critical aspect of quality improvement in healthcare settings (13). Primary care is a complex system of medical service that interacts with almost every individual repeatedly across their lifetime. Over time, patients seen routinely in primary care have become sicker, presenting with more than one chronic diagnosis (1, 4, 13). The prevalence of multimorbidity—defined as the coexistence of two or more long-term (chronic) medical conditions and/or diseases—in patients has significant impact on health services across the specialties. Much of the management of these comorbidities is taken on by the primary care physician. The complexities of patients’ medical management and support, in tandem with often fragmented health care systems, places large demand on primary care providers (4). This complexity of care contributes to provider burnout, burden of cost, decreased patient satisfaction, reduced productivity and efficiency, reduced access to timely care, and reduced patient outcomes (2, 4, 13, 15).

Although it has evolved since its inception, The Institute of Healthcare Improvement (IHI) introduced the Triple Aim in 2008 as a response to these complexities and poor outcomes as a framework approach to optimizing health system performance (8). They proposed that health systems should focus on improving a triple aim of care: improving patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the costs of health care (8). This triple aim of health care has been a focus of health system optimization – focusing on improving patient experience and population health, and on reducing healthcare costs (2). These factors, existing within a complex, fragmented, and often chaotic healthcare system (10), contribute to provider and professional burnout and poor patient satisfaction. Provider burnout is “characterized by loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment and is associated with early retirement, alcohol use, and suicidal ideation” (2). Due to these factors, the IHI in 2014 expanded the Triple Aim to include a fourth goal focused on combating provider burnout (11). In 2022, in light of the COVID pandemic response, the IHI introduced a fifth aim (now the Quintuple Aim of Healthcare) looking at equity, which asks health care leaders and practitioners “to identify disparities, design and implement evidence-based interventions to reduce them, invest in equity measurement, and incentivize the achievement of equity” (11).

These can all contribute to increased financial burden. Adding the fourth goal of improving the work experience of medical professionals – reducing burnout rates, and hopefully increasing productivity, improving patient satisfaction, and reducing costs (10). Well-functioning team-based care approaches have been shown to result in improved health outcomes, reduced provider burnout, improved patient outcomes and improved patient access to care.

PROBLEM

To understand the importance of learning collaboratives that advance and support team-based care, it’s critical to understand the underlying pain points these collaboratives address. Disjointed continuity of care, decreased productivity, and missed opportunities are major contributors to provider burnout, patient dissatisfaction, and increased costs. According to the Institute for Healthcare Improvement (IHI), “in American health care, the consequences of low quality are severe: high costs (40% higher than in the next most expensive nation); injuries to patients (between 40,000 and 100,000 Americans die in hospitals each year because of errors in their care); unscientific care (almost half of all clinically correct care is missing, based on reviews of patient records); and poor service” (7).
Fragmented continuity of care is multifactorial –poor communication between team members, unclear roles, multiple handoffs, silos between departments, and outdated technology or charting methods all contribute (6). Decreased productivity results from many of these same factors. Missed opportunities include patient no-shows, empty appointment slots, and poorly managed time.

As patients become sicker, with most primary care patients having multiple chronic illness diagnoses (2, 13), it becomes more and more critical for the workplace to function smoothly. Patient satisfaction is a critical indicator of quality improvement, patient outcomes, and improved healthcare costs, as it “affects clinical outcomes, patient retention […] the timely, efficient, and patient-centered delivery of quality health care” (12). Patient centered and collaborative care necessitates a healthcare design that allows a provider to respond to a patient’s individual strengths and challenges related to self-managing their illness when not with the provider (13).

Why does this matter? Patient satisfaction has been shown to be an important indicator for measuring the quality of health care. Studies have shown that patient satisfaction affects clinical outcomes and patient retention, and thus affects timely and patient-centered approaches to care delivery; these impact patient outcomes (10, 12) Improvement in these areas help decrease provider burnout (characterized by higher exhaustion, decreased professional efficacy, high cynicism, poor job satisfaction), which has been associated with increased medical errors, and increased costs (15). The US healthcare system accounts for 19.7% of the gross domestic product (5). Aging populations, in tandem with increased longevity, place further demand on the healthcare system, particularly when coupled with the increase in chronic health conditions and co- or multi-morbidities seen in individual patients (8).

INTERVENTIONS

Team-based primary care “involves redesign of staff roles and care delivery processes to improve efficiency and effectiveness” (14). This approach clarifies team role and responsibilities, improves communication, reduces duplication of tasks, improves productivity, and increases patient access to care. All of these, in turn, support the provider (reducing burnout), improve patient satisfaction, and reduce healthcare costs (2, 13, 14). A comprehensive roadmap for improving care was proposed as a conceptual model to guide providers in improving their workflow and patient outcomes (1). These “10 building blocks of high-performing primary care”, incorporate four foundational elements of care: engaged leadership, data-driven improvement, empanelment, and team-based care (1).

Learning collaboratives—such as the Dramatic Performance Improvement™ (DPI™ collaborative), and High Impact Management Program (HIMP) provided by Coleman Associates—utilize evidence-based & leadership-supported data and implementations to support and establish team-based care. Cultural and workflow change is often stagnant in healthcare (due in part to the inherently complex nature of healthcare systems); utilizing learning collaboratives to assist in training and supporting change over months can support the shift, turning “healthcare into a learning system, with participants attuned to system features and with strong feedback loops to try to build momentum for change” (3).

WHY CARE?

Team-based care may serve as one approach to combat the overwhelming demands of primary care. It has been shown to be instrumental in transforming and improving patient care in high-performing primary care practices and is one of the 10 building blocks of high-performing primary care (1, 14, 15). It has been shown to improve patient health outcomes, reduce provider burnout, and improve patient access (14). High-quality learning programs help clarify team roles and provide a structure for cultural change within the workplace; this in turn can reduce redundancy, improve efficiency and productivity, and improve patient access to care and patient satisfaction (2, 9, 14). Transitioning to a well-functioning interdisciplinary team-based approach to care is a challenging process; participation in a learning collaborative like DPI™ and HIMP can influence team functioning and facilitate the adoption of team-based care processes (9, 14).

As the population continues to age, live longer, and live with more comorbidities, it is imperative that primary care practices adopt a team-based approach to care—for the sake of both providers and patients.

REFERENCES

1. Bodenheimer, T., Ghorob A., Willard-Grace, R.m et al. The 10 building blocks of high-performing primary care. Annals of Family Medicine 2014; 12; 166-171.
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3. Braithwaite, J. Changing how we think about healthcare improvement. BMJ 2018; 351:k2014. doi: 10.1136/bmj.k2014
4. Cassell, A., Edwards, D., Harshfield, A., Rhodes, K., Brimicombe, J., Payne, R., & Griffin, S. The epidemiology of multimorbidity in primary care: a retrospective cohort study. 2018; British Journal of General Practice; e245-51.
5. Centers for Medicare and Medicaid Services (CMS). CMS office of the actuary releases 2021-2030 projections of national health expenditures, 2022. Retrieved from https://www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2021-2030-projections-national-health-expenditures [Accessed December 2022]
6. Coleman Associates, 2022. DPI (Dramatic Performance Improvement) Collaborative. Retrieved from https://colemanassociates.com/product/dpi-collaborative/ [Accessed December 2022]
7. Institute for Healthcare Improvement. The breakthrough series: IHI’s collaborative model for achieving breakthrough improvement, 2003.
8. Institute for Healthcare Improvement, 2023. The IHI Triple Aim. Retrieved from https://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx [Accessed December 2022]
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13. Sevin, C., Moore, G., Shepherd, J. et al. Transforming care teams to provide the best possible patient-centered, collaborative care. J Ambul Care Manage 2009; 32:24-31
14. Thies, K., Schiessl, A., Khalid, N., Hess, A. M., Harding, K., & Ward, D. Evaluation of a learning collaborative to advance team-based care in federally qualified health centers. BMJ Open Quality 2020; 9:e000794. doi: 10.1136/bmjoq-2019-000794
15. Willard-Grace, R., Hessler, D., Rogers, E., Dube, K., Bodenheimer, T., Grumbach, K. Team structure and culture are associated with lower burnout in primary care. Journal of American Board Family Medicine 2014; 27:229-38. doi: 10.3122/jabfm.2014.02.130215.