Collaborative Partnerships Within Integrated Behavioral Health and Primary Care

Fig. 10.1

Outline of a typical patient-centered care plan (PCCP)

Ultimately, the PCCP is a useable, electronic document that enables the health care team to care for the patient by providing the right interventions for the right person at the right time, to care about the patient by providing a system of care where each patient or family feels known, heard, and valued; to assign roles and responsibilities to the patient and team members; and to address goals and priorities. By using the PCCP, team functioning and patient care are enhanced (Council et al., 2012).

Quality of Evaluation and Strength of Research Evidence

Health care teams are ultimately formed to improve patient outcomes. There is a body of evidence showing that multidisciplinary team care leads to better patient health outcomes compared to usual care, although identifying which particular element of team care leads to improved outcomes is challenging. Bosch et al. (2009) examined literature on the effectiveness of health care teams on patient outcomes revealing that teams with improved coordination demonstrated positive effects on patient outcomes; however, the effects of the teams were limited in terms of costs and use of resources.

There are specific examples from the literature where team-based care has been shown to improve patient outcomes. Collaborative, interdisciplinary teams can reduce inpatient mortality (Aiken, Smith, & Lake, 1994; Knaus, Draper, Wagner, & Zimmerman, 1986; West et al., 2002), functional outcomes after surgeries (Borrill, West, Shapiro, & Rees, 2000; Gittell et al., 2000; Shortell et al., 2000; Uhlig, Brown, Nason, Camelio, & Kendall, 2002), care efficiencies (Borrill et al., 2000; Gittell et al., 2000). Heart failure care teams have been shown to reduce morbidity, enhance compliance, reduce rehospitalization, and prolong survival (Grady et al., 2000). Homebound chronically or terminally ill elderly managed by a home care team of physicians, nurse practitioners, and social workers had fewer hospitalizations, nursing home admissions, outpatient visits, and were more often able to die at home if this was their wish (Zimmer, Groth-Juncker, & McCusker, 1985). Patients with stage-three chronic kidney disease and comorbid diabetes and/or hypertension managed by a multidisciplinary team showed slower rates of decline in their renal function (Bayliss, Bhardwaja, Ross, Beck, & Lanes, 2011).

In addition to patient care outcomes, improved teamwork has lead to improved staff satisfaction and multiple studies now correlate improving staff satisfaction to improved patient satisfaction (Argentero, Dell’Olivo, & Ferretti, 2008; Borrill et al., 2000; Garman, Corrigan, & Morris, 2002; Hiss, 2006; Yang & Huang, 2005). Additionally, the work of nonphysician team members improves cancer-screening rates, office efficiency and care coordination, as well as patient and staff satisfaction (Anderson & Halley, 2008; Hudson et al., 2007; McAllister, Presler, & Cooley, 2007). Teams with higher levels of staff burnout have been shown to have significantly lower levels of patient satisfaction (Garman, Corrigan, & Morris, 2002).

Interprofessional education might also contribute to improved patient health outcomes, but the number of studies conducted in this area is limited and educating health professionals to work as a team has not clearly been associated with improved patient care outcomes. The limited number of studies found on this topic indicates that this is an area of opportunity for future research (Reeves et al., 2008).

Summary and Conclusion

The role of health care teams in patient care has expanded as complexity increases and as the number of diverse providers involved increases. Health care team members are wise to rely on the skills, expertise, and abilities of their fellow members, as an individual care provider is no longer able to effectively manage all the care needs of a single patient, particularly for those with more medically or socially complex concerns. Leading health and health education organizations support the important role of health care teams.

The characteristics of successful teams are difficult to define, but certainly there are key elements that are associated with team health. Many of these key elements are seen in the example health care teams in the section (The AIMS Center, Crozer-Keystone team, Concord Hospital Family Health Center team, University of California San Diego Family Medicine Residency team). Clear role definition, inclusive leadership, open communication, and a culture of respect for fellow team members are important characteristics of effective teams.

Collaborative partnerships: and initiatives	Vision, purpose, rationale	Health care context	Partnerships factors and qualities	Sustainability and continuity of partnerships	Evaluation/research evidence	Benefits and obstacles
Health care teams	Coordinate care, improve patient care decision making	Various settings: acute care, primary care, disease oriented, population oriented	Leadership inclusiveness vision communication respect	Variable continuity and sustainability	Evidence supports health care teams improving patient care outcomes	Benefits: less duplication of efforts

References

AAMC Center for Workforce Studies. (2010). Physician shortages to worsen without increases in residency training. Retrieved April 15, 2012 from April, 2012 https://www.aamc.org/download/150584/data/physician_shortages_factsheet.pdf

Aiken, L. H., Smith, H. L., & Lake, E. T. (1994). Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care, 32(8), 771–787.PubMedCrossRef

American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. (2007). Joint principles of the patient-centered medical home.

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