Team-Based Care

Last evening, I had the pleasure of introducing Dr. Jay Perman, President of the University of Maryland at Baltimore, who spoke at the health system about interprofessionalism, which succinctly put is team-based care.  He talked about how team-based care is optimal  for our patients, its importance in our transition to value-based care delivery, and how it results in better quality and allows us to better address the socioeconomic factors that our patients experience.  

Team-based care involves a care team that may include physicians, nurse practitioners, RNs, respiratory therapists, pharmacists, dietitians,  dentists, attorneys, social workers, care managers, physical and occupational therapists, physician assistants and the list goes on.  In addition to teaching the concept, Dr. Perman uses the team-based approach in his clinic when he sees patients.  After his presentation, I offered an example here at WMHS  that supports his concept of interprofessionalism. 

Our Center for Clinical Resources was built around team-based care delivery.  I explained that when WMHS began our demonstration project on value-based care delivery, we learned that there were 1,972 patients who accounted for $140 million of our cost.  Obviously, these were patients with multiple co-morbidities such as diabetes, congestive heart failure (CHF), COPD and hypertension. To help these patients manage their conditions, we opened a Diabetes Clinic and a CHF Clinic and then added an Anti-Coagulation Clinic.  Unfortunately, all were in separate locations, both on and off campus and it was difficult for patients who had appointments in more than one clinic.  It was then that we decided to combine all of the clinics into one location, the Center for Clinical Resources.  We moved the separate clinics to one office suite in our medical office building and decided not to charge any co-pays or deductibles .  We consolidated the pharmacists in our Anti-Coagulation Clinic, the Diabetes Clinic and its team of a nurse practitioner, a dietician and others, along with the CHF team that was led by a nurse practitioner.  We then added a navigator, respiratory therapists, nurses and other key staff all with access to physicians who specialize in each area.  Through the team approach, we provide a more comprehensive level of care to these patients with multiple illnesses.  They can get their care in one location by a team that is focused on them specifically.  We have reduced admissions, readmissions, ED visits and ancillary utilization for these patients, resulting in a saving of over $8 million in less two years.  Through this approach and a host of other initiatives those 1,972 patients incurring $140 million in cost is now 1300 patients incurring $80 million.

None of our successes in value-based care delivery or the Center for Clinical Resources could have been achieved without using the team-based care approach.  It was also nice to be able to provide Dr. Perman with a real live success story related to his passion for interprofessionalism.