Case Scenario: The Team Can See You Now

A visit to the doctor may mean seeing someone else instead. An increasing number of practices are scrapping the traditional oneon-one doctor-patient relationship. Instead, patients are receiving care from a group of health professionals who divide up responsibilities that once would have largely been handled by the doctor in charge. While the supervising doctor still directly oversees patient care, other medical professionals-nurse practitioners, physician assistants and clinical pharmacists-are performing more functions. These include adjusting medication dosage, ensuring that patients receive tests and helping them to manage chronic diseases. "I can't possibly do everything that needs to be done for our patients as a single human being," says Kirsten Meisinger, supervising physician for a team of between 9 and 11 medical professionals at the Union Square Family Health Center in Somerville, Mass., one of 15 primary-care centers run by Harvard Medical School affiliated Cambridge Health Alliance. For example, Dr. Meisinger says she may see a diabetic patient once every three months. But nurses on her team generally see the patient more frequently and for longer visits.

And patients are likely to feel more comfortable telling a nurse than a doctor if, for instance, they haven't been taking their medication, she says. The new approach, called team based care, comes amid a shortage in many parts of the U.S. of primary-care physicians, a situation expected to worsen as the number of new patients obtaining insurance under the federal Affordable Care Act rises. Pervasive chronic diseases such as diabetes also are straining the health-care system. "In many primary-care practices today, physicians are doing a great deal of work that could be done by others on the team," says Don Goldmann, chief medical officer of the Institute for Healthcare Improvement, in Cambridge, Mass., a nonprofit that works with medical practices to improve delivery of health care. Dr. Goldmann expects that within 10 years team based care "will be the norm." Team-based care is also becoming more common as large healthcare providers increasingly purchase private physician practices and shift from traditional fee-for-service payments to other models, such as those that provide fixed payments to care for patients over a set time. Lucas Calixto, a 24-year-old softwareimplementation engineer, ended up in the emergency room with a pulmonary embolism, a blockage in a lung artery caused by a blood clot last summer. He is now on blood-thinning medication and needs close monitoring to prevent a recurrence. On his regular visits to the Union Square clinic, he often doesn't see the doctor.

Instead, another member of the medical team, clinical pharmacist Joseph Falinski, who has a doctor of pharmacy degree, monitors the levels of medication in his system and adjusts the dose as needed. Mr. Calixto also meets with registered nurse Amberly Killmer, who talks to him about how his condition is affecting his life and whether he is adhering to his diet and exercise regimen. Dr. Meisinger says she diagnoses and treats patients like Mr. Calixto initially, then gives guidance to the team for follow-up. Mr. Calixto feels confident in the care he receives from other team members. "To be honest, unless it is an emergency, they can address whatever issue I'm having and they always seem to do a good job," he says. The idea of team-based care is to allow the team members to practice at the highest level allowed by their training and medical license. Physician assistants, for example, complete graduate-level programs lasting on average 27 months and do clinical rotations in different specialties. They can examine patients, diagnose injuries and illnesses, provide treatment, prescribe medications and perform some surgical procedures. But they must be under the supervision of physicians, and the care they can provide varies widely by state and by health-care provider. Studies have shown that teambased care can improve patient outcomes and reduce costs. A 2012 study looked at 214 adults with depression, combined with either diabetes or heart disease or both.

It found that after two years, patients overseen by a team of nurses, working under primary-care-doctor supervision, were significantly less depressed and had improved levels of blood sugar, cholesterol and blood pressure, compared with patients who didn't receive nurse coaching and monitoring. The study, conducted by the University of Washington and the research arm of Group Health, a nonprofit health-care provider in Seattle, also found that for patients, whose care cost $11,000 annually on average, team-based care was associated with nearly $300 in yearly savings at Group Health, which charges a fixed monthly rate for unlimited care. Winning over patients to teambased care can be a challenge. A 2012 survey of more than 1,000 lowincome people in California by the Blue Shield of California Foundation found that the majority preferred to be seen by doctors. About 1 in 4 of the respondents already had teambased care, and 94% of them said they liked it. Among those who didn't have team-based care, 81% said they were willing to try it. Doctors may resist being part of a team and ceding care of their patients, studies have found. Experts in health-care delivery also caution that team members must coordinate care and delegate clearly to avoid anything falling through the cracks. At the Somerville Union Square clinic, team members meet in "huddles" usually twice a day to review incoming patients and decide who needs to see them. The meetings also aim to identify which patients may need extra attention. Patients who are chronically late, for instance, may get assistance from Paula Coutinho, a clinical social worker, who might arrange transportation or child care. Physician assistant Juliane Liberus is often the first practitioner new patients see.

She will take medical histories, review medications and perform physical exams. "I do well-child visits, geriatric care, the whole gamut of things," she says. If needed, Ms. Liberus will refer cases to Dr. Meisinger for follow-up. Dr. Meisinger says the team helps her with countless behind-the-scenes tasks, like the medical assistants and receptionists who follow up on abnormal mammogram results and chase down patients to come in for colonoscopy tests. "We literally have lists of the lives they've saved," Dr. Meisinger says. Medical assistant Fabiola Marcelin, who is also a phlebotomist, does blood work and explains to patients how to do certain tests, such as fecal occult blood tests for colon cancer. Ms. Killmer, the registered nurse, says she sometimes has to educate patients about the team members' different roles and explain to patients that they may not need the doctor for certain things. Sometimes if a patient insists on seeing the doctor, Dr. Meisinger will look into the room and assure the patient that Ms. Killmer's plan is a good one. "That little bit of interaction makes patients feel like, hey, I saw the doctor, but I have a pretty smart nurse," says Ms. Killmer.

Questions for Discussion: 1. How might using teams in health care settings enhance performance, responsiveness to patients, and health care provider motivation?

2. What kind of interdependence do you think exists in teams in health care settings?

3. What kinds of norms do you think it would be important for these teams to have?

4. Why might it be important for teams in health care settings to have a moderate level of cohesiveness?