This page provides an introduction to team-based care and contains tools, articles, and guides on implementing team-based care practices. These resources have been designed and selected to help Community Health Centers and Primary Care Associations pursue this model of care. Please contact the CHAMPS Clinical Quality Improvement Director if you have any questions about these materials or would like to share any other useful resources.
Please click or scroll down for:
Introduction
Articles and Reports
Education and Training
Tools for Implementing Team-Based Care
Other Recommended Resources
Special Topics:
Care Coordination Resources
Motivational Interviewing Resources
INTRODUCTION
Team-based care is a model of health services delivery that provides comprehensive care to patients, families, and communities. In this model, a minimum of two health care professionals work together with patients, caregivers, and other service providers on health-related goals within, across, and beyond the healthcare setting to deliver thorough, dynamic, safe, patient-centered, inclusive, and equitable care.
Team-based care is not a new approach, with origins in the chronic care model, and is now the “norm” at some level in most organizations. This model is an integral part of Patient-Centered Medical Home (PCMH) recognition, imperative to attaining advanced access, and important when working on flow, improving chronic care management, and addressing preventive screening and follow-up.
For CHAMPS’ information and resources on Patient-Centered Medical Home (PCMH), click here.
ARTICLES AND REPORTS
The 10 Building Blocks of High-Performing Primary Care
Annals of Family Medicine
Thomas Bodenheimer, MD, Amireh Ghorob, MPH, Rachel Willard-Grace, MPH, and Kevin Grumbach, MD (2013)
www.annfammed.org/content/12/2/166.full
Lays out the essential elements of primary care, based studies exemplary primary care practices and work assisting practices to become more patient-centered.
Association Between Measured Teamwork and Medical Errors: An Observational Study of Prehospital Care in the USA
The BMJ
Simone Herzberg, et al. (2019)
bmjopen.bmj.com/content/9/10/e025314
Study used a validated instrument, the Clinical Teamwork Scale (CTS), to measure overall teamwork in 44 teams of emergency medical services (EMS) professionals as they responded to 176 simulations of pediatric emergencies. Results indicated that fewer errors were made by teams with higher (better) CTS scores.
Core Principles & Values of Effective Team-Based Health Care
Institute of Medicine (IOM)
Pamela Michell, et al. (2012)
nam.edu/perspectives-2012-core-principles-values-of-effective-team-based-health-care/
Provides common reference points to guide coordinated collaboration among health professionals, patients, and families — ultimately helping to accelerate interprofessional team-based care.
Creating Patient-Centered Team-Based Primary Care
Agency for Healthcare Research and Quality (AHRQ)
Lisa Schottenfeld, MPH, MSW, et al. (2016)
pcmh.ahrq.gov/sites/default/files/attachments/creating-patient-centered-team-based-primary-care-white-paper.pdf
Proposes a conceptual framework for the integration of team-based care and patient-centered care in primary care settings; and offers some practical strategies to support the implementation of patient-centered team-based primary care.
Educating Health Professionals Collaboratively For Team-Based Primary Care
Health Affairs
Brian Schuetz, Erin Mann, and Wendy Everett (2010)
www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.0052
Acknowledges that the broader adoption of team-based care is hindered by an education system that trains health professions in silos and proposes a solution to this challenge with collaborative models that educate multiple practitioners together.
The Effectiveness and Applicability of Motivational Interviewing: A Practice-Friendly Review of Four Meta-Analyses
Journal of Clinical Psychology
Brad Lundahl and Brian L. Burke (2009)
onlinelibrary.wiley.com/doi/abs/10.1002/jclp.20638
Reviews the research support for Motivational interviewing (MI) so that practitioners can make informed decisions about the value and applicability of MI in their clinical work.
Enhancing the Role of the Nurse in Primary Care: The RN “Co-Visit” Model
Journal of General Internal Medicine
Karen A. Funk, MD, MPP and Malia Davis, MSN, ANP-C (2015)
cchn.org/wp-content/uploads/2018/02/Enhancing-the-Role-of-the-Primary-Care-Nurse-The-RN-Co-Visit-Model-.pdf
Discusses Clinica Family Health’s transformation of the Registered Nurse role and how this addresses goals of patient access and workforce job satisfaction.
Future of Nursing Report
National Academy of Medicine (NAM) (Formerly Institute of Medicine) (2010)
www.nursingworld.org/practice-policy/iom-future-of-nursing-report/
Makes recommendations for an action-oriented blueprint for the future of nursing.
High Plains Community Health Center – Redesign Expands Medical Assistant Roles
Center for the Health Professions
Lisel Blash, Catherine Dower, and Susan Chapman (2011)
cchn.org/wp-content/uploads/2018/02/MA-Step1-High-Plains-Redesign-Expands-Medical-Assistant-Roles.pdf
Outlines workflow redesign and impact on productivity, cost-savings, and other benefits for patients and staff.
Implementing Optimal Team-Based Care to Reduce Clinician Burnout
NAM Perspectives
Cynthia D. Smith, et al. (2018)
nam.edu/implementing-optimal-team-based-care-to-reduce-clinician-burnout/
Discussion paper which describes key features of successful health care teams, reviews existing evidence that links high-functioning teams to increased clinician well-being, and recommends strategies to overcome key environmental and organizational barriers to optimal team-based care in order to promote clinician and patient well-being.
Long-Term Effects of Teamwork Training on Communication and Teamwork Climate in Ambulatory Reproductive Healthcare
Journal of Healthcare Risk Management
Laura E. Dodge, Siripanth Nippita, et al. (2020)
psnet.ahrq.gov/issue/long-term-effects-teamwork-training-communication-and-teamwork-climate-ambulatory
Evaluation that assesses the long-term impact of implementing TeamSTEPPS in ambulatory reproductive health care centers. After two years, survey results indicate that TeamSTEPPS implementation was associated with improved perceptions of teamwork and patient satisfaction and that these tools and strategies were successfully integrated into health center operations.
Patient-Centered, Integrated Health Care Quality Measures Could Improve Health literacy, Language Access, and Cultural Competence
Ignatius Bau, JD, et al. (2019)
nam.edu/patient-centered-integrated-health-care-quality-measures-could-improve-health-literacy-language-access-and-cultural-competence/
Recommends the integration of health care quality improvement measures for health literacy, language access, and cultural competence. Also notes the importance of patient-centered and equity-based institutional performance assessments or monitoring systems.
Performance Dashboards: Defining and Creating an Effective Tool for Management
Coleman Associates (2016)
colemanassociates.com/wp-content/uploads/2016/03/Performance-Dashboards-Article-.pdf
Defines and outlines successful strategies for implementing performance dashboards.
Practice Transformation: Using Team-Based Care Training to Improve Diabetes Outcomes
Journal of Primary Care & Community Health
Lori A. Bilello, Christopher Scuderi, Charles J. Haddad, Carmen Smotherman, and Edward Shahady (2018)
www.ncbi.nlm.nih.gov/pmc/articles/PMC6295684/
Outlines the necessity of shifting mental models at the individual level and culture change at the practice level on how clinicians and support staff work together.
Radical Redesign: The Power of Team-Based Care
Annals of Family Medicine
James Jerzak, MD (2017)
www.annfammed.org/content/15/3/281.full
Discusses the system-wide transformation of Bellin Health to advance team-based care in preparation for the impending change to value-based care.
Team-Based Care: Optimizing Primary Care for Patients and Providers
Institute for Healthcare Improvement (IHI)
Cindy Hupke (2014)
www.ihi.org/communities/blogs/team-based-care-optimizing-primary-care-for-patients-and-providers-
Answers common questions about team-based care and describes its advantages for patients and providers.
Team-Based Care Primary Care: Opportunities and Challenges
Starfield Summit
Diana M. Wohler, MD and Winston Liaw, MD, MPH (2016)
www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/StarfieldSummit_Report_TeamBasedPrimaryCare.pdf
Discusses the system-wide transformation of Bellin Health to advance team-based care in preparation for the impending change to value-based care.
EDUCATION AND TRAINING
Implementing Team-Based Care: Engage the Entire Team in Caring for Patients
American Medical Association (AMA) (2015)
edhub.ama-assn.org/steps-forward/module/2702513
Module that illustrates the impact of the practice model, provides step-by-step implementation guidance, and offers resources and documents that can assist with implementation.
Improving Primary Care Team Guide: Scribing Model: Two Clinical Assistants with One Provider
The Primary Care Team: Learning From Effective Ambulatory Practices (LEAP) (2014)
www.youtube.com/watch?v=lfuxH3htduM
Video explaining the Scribing Model, where one provider has two flow staff (MAs or LPNs), called Clinical Assistants, who are trained to scribe and work with patients to ensure they understand information from the provider.
Optimizing Team Resources: Patient/Provider Scheduling and Panel Size
Capital Link
register.gotowebinar.com/register/3829137593121611267
Archived webinar that looks at techniques designed to expand capacity utilizing existing resources within a sustainable structure.
Peak Vista Community Health Center, CO, Team-Based Care Success Video
John Snow, Inc. (2017)
www.youtube.com/watch?v=NzNyZD8uox0
Video in which team members share their successes with the team-based care model.
Primary Care Transformation Pioneer Dr. Tom Bodenheimer on Need for More Team-Based Care
Conversations on Health Podcast
CHC Inc. (2019)
www.chcradio.com/episode.php?id=509
Discussion of the “Ten Building Blocks for High-Performing Primary Care” which offers essential guidelines for improving primary care practices and patient health outcomes through better use of teams, data, health coaching and reducing administrative burdens in the clinical setting.
The Physician Experience of Team-Based Care
The Primary Care Team: Learning From Effective Ambulatory Practices (LEAP) (2018)
vimeo.com/238463756
Video in which physicians from exemplary sites share their experiences of team-based care clinical practices.
TOOLS FOR IMPLEMENTING TEAM-BASED CARE
Core Competencies for Behavioral Health Providers Working in Primary Care
Eugene S. Farley, Jr. Health Policy Center
farleyhealthpolicycenter.org/core-competences-for-behavioral-health-providers-working-in-primary-care/
List and explanations of the eight core competencies for licensed behavioral health providers working in primary care.
Free White Noise Downloads
The MC² Method
www.mc2method.org/white-noise/
Downloadable white noise sounds to enhance privacy and mask discrete sounds.
Implementing Team-Based Care: Resources
American Medical Association (AMA)
edhub.ama-assn.org/steps-forward/module/2702513#resource
Resources and documents for Team-Based Care implementation including checklists, questionnaires, tool kits, and core concepts and principles.
The Primary Care Team Guide
The Primary Care Team: Learning From Effective Ambulatory Practices (LEAP)
improvingprimarycare.org/
Provides step-by-step directions on how to establish high-functioning teams and implement new functions essential to team-based care.
Registered Nurses: Partners in Transforming Primary Care
Macy Foundation
cchn.org/wp-content/uploads/2018/02/Macy-2016_Nursing_Conference_Exectuive_Summary_Final.pdf
Recommendations on preparing Registered Nurses for enhanced roles in primary care.
Simon Sinek: How Great Leaders Inspire Action
TED
www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action
Explores how leaders can inspire cooperation, trust, and change.
Situation-Behavior-Impact (SBI) Feedback Tool
The Center for Creative Leadership
www.mindtools.com/pages/article/situation-behavior-impact-feedback.htm
Tool that helps users deliver more effective feedback. Focuses comments on specific situations and behaviors, and outlines the impact that these behaviors have on others.
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)
Agency for Healthcare Research and Quality (AHRQ)
www.ahrq.gov/teamstepps/index.html
Evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals.
Ten Building Blocks for High-Performing Primary Care
Annuls of Family Medicine
www.annfammed.org
Guidelines for improving primary care practices and patient health outcomes through better use of teams, data, health coaching and reducing administrative burdens in the clinical setting.
Three Keys to Prep Your Staff for Success with Team-Based Care
American Medical Association (AMA)
www.ama-assn.org/practice-management/payment-delivery-models/3-keys-prep-your-staff-success-team-based-care
Information on how to help staff transition to team-based care.
When Teams Work Best: 6,000 Team Members and Leaders Tell What It Takes to Succeed
SAGE Publications, Inc.
Carl Larson and Frank LaFasto (2001)
us.sagepub.com/en-us/nam/when-teams-work-best/book19666
Deeply probes inside the workings of hundreds of teams―some effective and some faltering.
OTHER RECOMMENDED RESOURCES
Authentic Conversations: Moving from Manipulation to Truth and Commitment
Berrett-Koehler Publishers, Inc.
Jamie Showkeir and Maren Showkeir (2008)
www.bkconnection.com/books/title/authentic-conversations
Shows how ordinary conversation can lead to a workforce that is engaged and energized or to one that is alienated and uninspired.
Center for Care Innovations
www.careinnovations.org/
Resources and programs to cultivate innovation within organizations impacting care and services for low-income and disadvantaged populations.
Five Dysfunctions of a Team
Jossey-Bass
Patrick Lencioni (2002)
www.tablegroup.com/books/dysfunctions
Outlines the root causes of politics and dysfunction on the teams where you work, and the keys to overcoming them.
Good to Great: Why Some Companies Make the Leap…and Others Don’t
William Collins
James C. Collins (2001)
www.jimcollins.com/books.html
Describes how companies transition from being good companies to great companies, and how most companies fail to make the transition.
Institute for Healthcare Improvement (IHI)
www.ihi.org/Pages/default.aspx
Uses improvement science to advance and sustain better outcomes in health and health care across the world.
Results that Last: Hardwiring Behaviors That Will Take Your Company to the Top
Wiley
Quint Studer (2007)
www.wiley.com/en-us/Results+That+Last%3A+Hardwiring+Behaviors+That+Will+Take+Your+Company+to+the+Top-p-9780471757290
Information on how to build an organizational culture that develops great leaders today and instills the mechanisms and the mindset that will continue to foster great leadership tomorrow.
Society for Human Resources Management (SHRM)
www.shrm.org
Resources and tools for human resources management.
Thanks for the Feedback: The Science and Art of Receiving Feedback Well
Viking Press
Douglas Stone and Sheila Heen (2014)
www.penguinrandomhouse.com/books/313485/thanks-for-the-feedback-by-douglas-stone-and-sheila-heen/9780143127130/
How to turn evaluations, advice, criticisms, and coaching into productive listening and learning.
There Is No ‘I’ in Team: Taking Care of the Team that Cares for Patients with Substance Use Disorder
National Association of Community Health Centers (NACHC) (2019)
champsonline.org/assets/files/ToolsProducts/ClinicalResources/SUDDocs/CompassionateCareInfographic_032619_NACHC.pdf
Infographic on mitigating the strain treating patients with substance use disorder has on the workforce
The Truth of Employee Engagement (originally published as Three Signs of a Miserable Job: A Fable for Managers)
Jossey-Bass
Patrick Lencioni (2007)
www.tablegroup.com/books/engagement
Demonstrates how career happiness (or misery) is the direct result of the manager-employee relationship.
SPECIAL TOPICS
CARE COORDINATION RESOURCES
Care Coordination
Agency for Healthcare Research and Quality (AHRQ)
https://www.ahrq.gov/ncepcr/care/coordination.html
An overview and explanation of care coordination.
Caring for Yourself When You are a Care Coordinator
Patient Navigator Training Collaborative (PNTC), CHAMPS
Lucille Campbell, PhD.H (2019)
http://champsonline.org/assets/files/Events/DistanceDocuments/CareCoordinationEssentials-SelfCare_ParticipantHandouts.pdf
A PowerPoint presentation outlining the importance of well-being and developing a self-care plan targeted towards Care Coordinator lifestyles.
Healing Hands: Care Coordination
National Health Care for the Homeless Council (NHCHC)
https://nhchc.org/wp-content/uploads/2019/08/healinghands-care-coordination-final-web-ready.pdf
An article outlining the goals and challenges of implementing care coordination programs with case studies presented for modeling.
Health Network: A Care Coordination Program for Mobile Patients
Migrant Clinicians Network (MCN)
https://www.migrantclinician.org/webinar/health-network-care-coordination-program-mobile-patients-.html
An archived webinar discussing care coordination for mobile patients with opportunity to earn continuing education credits.
How are We Doing? How to Evaluate Your Patient Navigation Program
Patient Navigator Training Collaborative (PNTC)
https://patientnavigatortraining.org/wp-content/uploads/2014/07/PN-Evaluation-Toolkit.pdf
A toolkit for program evaluation, goal setting, and data collection.
Motivational Interviewing for Care Coordinators
Patient Navigator Training Collaborative (PNTC), CHAMPS
Katie Langland, MA (2017)
http://champsonline.org/assets/files/Events/DistanceDocuments/CareCoordinationEssentials-MIforCareCoordinators_ParticipantHandouts.pdf
A PowerPoint slide presentation on motivational interviewing and strategies for engaging patients.
Navigating Families in Conflict
Patient Navigator Training Collaborative (PNTC), CHAMPS
Rebecca Richey, Psy.D (2019)
http://champsonline.org/assets/files/Events/DistanceDocuments/CareCoordinationEssentials-FamilyConflict_ParticipantHandouts.pdf
A PowerPoint slide presentation detailing strategies for planning interventions with families in conflict.
Pathways for Specialty Care Coordination and Integration in Population-based Models
Centers for Medicare and Medicaid Services (CMS)
https://www.cms.gov/blog/pathways-specialty-care-coordination-and-integration-population-based-models
A blog-style overview of research outlining CMS’ strategy to connect primary care to specialty care utilizing care coordination.
Patient Navigator Training Collaborative
Patient Navigator Training Collaborative (PNTC)
https://patientnavigatortraining.org/
Leadership resources and tools for the development, education, standardization, and sustainability of the patient navigation workforce.
Promotores and Promotoras de Salud
MHP Salud
https://mhpsalud.org/our-chw-initiatives/promotoras-de-salud/
An explanation of community health workers and MHP Salud’s Navigator Program for community members.
Rural Care Coordination Toolkit
Rural Health Information Hub (RHIhub)
https://www.ruralhealthinfo.org/toolkits/care-coordination
Modules outlining different aspects of care coordination programs to help rural communities implement the right program.
Role of Community Health Workers
U.S. Department of Health and Human Services (HHS)
https://www.nhlbi.nih.gov/health/educational/healthdisp/role-of-community-health-workers.htm
Community Health Worker Health Disparities Initiative discussion of the role of community health workers as frontline agents of change.
Types of Care Coordinators
Rural Health Information Hub (RHIhub)
https://www.ruralhealthinfo.org/toolkits/care-coordination/2/care-coordinator-model/types
Definitions of different types of care coordinator positions and the services they provide.
What are Patient Navigators and How Can They Improve Integration of Care
European Observatory on Health Systems and Policies
https://static.prod01.ue1.p.pcomm.net/integratedwork/user_content/forums/topics/files/930/7c0b33b929a4ffda32c429fdb1c1ccb1-patient-navigators-policy-brief.pdf?utm_medium=email&utm_campaign=website&utm_source=community.integratedwork.com
A policy brief on patient navigators and the integration of care globally.
What We Do
National Association of Community Health Workers (NACHW)
https://nachw.org/about/
An organization for frontline public health professionals to unify community health workers and provide resources and tools.
MOTIVATIONAL INTERVIEWING (MI) RESOURCES
Building Motivational Interviewing Skills: A Practitioner Workbook
Guilford Press
David B. Rosengren (2009)
www.guilford.com/books/Building-Motivational-Interviewing-Skills/David-Rosengren/9781462532063
Engaging, user-friendly workbook.
Conversations for Change Series Videos
Behavioral Health and Wellness Program of the University of Colorado Anschutz Medical Campus
www.bhwellness.org/conversations-for-change-series/
Video series designed to be viewed in order and as part of a facilitated educational process. For individuals using these videos without a facilitator or in a training setting, there are accompanying worksheets to support learning.
Motivational Interviewing
C4 Innovations
c4innovates.com/training-technical-assistance/motivational-interviewing/
Webpage explaining MI and offering resources, training, and technical assitance.
Motivational Interviewing: A Tool for Behavior Change
The American College of Obstetrics and Gynocologists (ACOG) (2009)
www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2009/01/motivational-interviewing-a-tool-for-behavior-change
Article describing the potential behavior change that can be elicited through MI; includes Current Procedural Terminology (CPT) codes are available to aid in obtaining reimbursement for time spent engaging patients in motivational interviewing for some conditions.
Motivational Interviewing: Helping People Change
Guilford Press
Stephen Rollnick & William Richard Miller (2012)
www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781609182274
Information on the development of new applications within and beyond the addictions field.
Motivational Interviewing in Health Care: Helping Patients Change Behavior
Guilford Press
Christopher C. Butler, Stephen Rollnick, and William Richard Miller (2007)
www.guilford.com/books/Motivational-Interviewing-in-Health-Care/Rollnick-Miller-Butler/9781593856120
Presents tools to enhance communication with patients and guide them in making choices to improve their health, from weight loss, exercise, and smoking cessation, to medication adherence and safer sex practices.
Motivational Interviewing in the Treatment of Psychological Problems
Guilford Press
Hal Arkowitz, William R. Miller, and Stephen Rollnick (2015)
www.guilford.com/books/Motivational-Interviewing-in-the-Treatment-of-Psychological-Problems/Arkowitz-Miller-Rollnick/9781462530120
Guides readers on how to incorporate motivational interviewing techniques in their clinical practice, summarizes current research on the wide-ranging application of motivational interviewing, and highlights new and promising directions.
Motivational Interviewing Streaming Videos
Motivational Interviewing Network of Trainers (MINT) (2013)
motivationalinterviewing.org/mi-streaming-videos
Collection of MI training videos.
Motivational Interviewing Toolkit
Institute for Research, Education, & Training in Addiction (IRETA) (2018)
ireta.org/resources/motivational-interviewing-toolkit/
Supplement to formal MI training including a collection of resources for practitioners.
Motivational Interviewing Tools and Techniques
Missouri Institute of Mental Health (2017)
adept.missouri.edu/wp-content/uploads/2017/06/Module-Two-Motivational-Interviewing-Tools-and-Techniques.pdf
Collection of philosophy, general techniques, and tools to help facilitate Motivational Interviewing.
The Pursuit of the Three C’s Video Series
Behavioral Health and Wellness Program of the University of Colorado Anschutz Medical Campus (2016)
www.bhwellness.org/pursuit-of-the-three-cs-series/
Videos intended to assist healthcare providers to have better conversations with parents regarding vaccination and immunization recommendations.