Skip to main content

Team-Based Care

  • Chapter
  • First Online:
Chronic Illness Care

Abstract

Caring for patients with chronic disease has become increasingly complex, and coordinating the many facets of medical and social care can be challenging to a clinician. Teams of health professionals working together and communicating regularly can provide such care more effectively. Successful integration of team-based care into practices improves outcomes for patients while decreasing costs associated with chronic illness. Clinicians and staff also benefit from the team approach due to increased career satisfaction. Team-based care is crucial in providing quality care while optimizing resources and minimizing costs.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Richardson W, Berwick DM, Bigard JC, et al. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: Institute of Medicine; 2001.

    Google Scholar 

  2. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246–51.

    Article  CAS  PubMed  Google Scholar 

  3. Reiss-Brennan B, Brunisholz KD, Dredge C, et al. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316(8):826–34.

    Article  PubMed  Google Scholar 

  4. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA. 2002;288(15):1909–14.

    Article  PubMed  Google Scholar 

  5. Schottenfeld L, Petersen D, Peikes D, et al. Creating patient-centered team-based primary care. Rockville: Agency for Healthcare Research and Quality, US Department of Health and Human Services; 2016.

    Google Scholar 

  6. Naylor M, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: state of the science. [Unpublished white paper]. 2010.

    Google Scholar 

  7. Wagner E. The role of patient care teams in chronic disease management. BMJ. 2000;320:569–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Wise H, Beckhard R, Rubin I, Kyte AL. Making health teams work. Cambridge, MA: Ballinger Publishing Co; 1974.

    Google Scholar 

  9. Redesigning the health care team: diabetes prevention and lifelong management. Bethesda: NIH National Diabetes Education Program. 2011. Contract No.: Publication No. 11–7739 NDEP-37.

    Google Scholar 

  10. Gomes B, Calanzani N, Gysels M, Hall S, Higginson IJ. Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care. 2013;12:7.

    Article  PubMed  PubMed Central  Google Scholar 

  11. The Patient Centered Medical Home History. Seven core features, evidence and transformational change. Washington, DC: Robert Graham Center; 2007.

    Google Scholar 

  12. Wagner E, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;4:511–44.

    Article  Google Scholar 

  13. Reid R, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835–43.

    Article  Google Scholar 

  14. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Project Hope). 2001;20(6):64–78.

    Article  CAS  Google Scholar 

  15. Wagner E. Chronic disease management. What will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2–4.

    CAS  PubMed  Google Scholar 

  16. Tsai A, Morton SC, Mangione CM, et al. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care. 2005;11(8):478–88.

    PubMed  PubMed Central  Google Scholar 

  17. Erickson C, Splett PL, Mullett SS, et al. The healthy learner model for student chronic condition management – part I. J Sch Nurs. 2006;22(6):310–8.

    Article  PubMed  Google Scholar 

  18. Health Sciences Institute. 2017. Available from: http://www.healthsciences.org/Infographic-The-Costs-of-Chronic-Disease-Implications-for-Health-Care.

  19. CDC. Team care approach for diabetes management. 2017. Available from: https://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide-team-care-approach.pdf.

  20. NIH. Redesigning the health care team: diabetes prevention and lifelong management. 2017. Available from: https://www.niddk.nih.gov/health-information/health-communication-programs/ndep/health-care-professionals/team-care/Pages/publicationdetail.aspx.

  21. Wagner E, Grothaus LC, Sandhu N, et al. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Diabetes Care. 2001;24(4):695–700.

    Article  CAS  PubMed  Google Scholar 

  22. Rubin R, Peyrot M, Siminerio LM. Health care and patient-reported outcomes: results of the cross-national diabetes attitudes, wishes and needs (DAWN) study. Diabetes Care. 2006;29(6):1249–55.

    Article  PubMed  Google Scholar 

  23. Grady K, Dracup K, Kennedy G, et al. Team management of patients with heart failure: a statement for healthcare professionals from the cardiovascular nursing council of the American Heart Association. Circulation. 2000;102(19):2443–56.

    Article  CAS  PubMed  Google Scholar 

  24. Bellam N, Kelkar AA, Whellan DJ. Team-based care for managing cardiac vomorbidities in heart failure. Heart Fail Clin. 2015;11(3):407–17.

    Article  PubMed  Google Scholar 

  25. Creaser J, DePasquale EC, Vandenbogaart E, et al. Team-based care for outpatients with heart failure. Heart Fail Clin. 2015;11(3):379–405.

    Article  PubMed  Google Scholar 

  26. Wever-Pinzon O, Drakos SG, Fang JC. Team-based care for heart failure. Heart Fail Clin. 2015;11(3):467–77.

    Article  PubMed  Google Scholar 

  27. Jaarsma T. Inter-professional team approach to patients with heart failure. Heart. 2005;91(6):832–8.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Doughty R, Wright SP, Pearl A, et al. Randomized, controlled trial of integrated heart failure management the Auckland heart failure management study. Eur Heart J. 2002;23:139–46.

    Article  CAS  PubMed  Google Scholar 

  29. Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation. 2002;105:2861–6.

    Article  PubMed  Google Scholar 

  30. Louis A, Turner T, Gretton M, et al. A systematic review of telemonitoring for the management of heart failure. Eur J Heart Fail. 2003;5:583–90.

    Article  PubMed  Google Scholar 

  31. DeBar L, Kindler L, Keefe FJ, et al. A primary care-based interdisciplinary team approach to the treatment of chronic pain utilizing a pragmatic clinical trials framework. Transl Behav Med. 2012;2(4):523–30.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Cheatle M, Klocek JW, McLellan AT. Managing pain in high-risk patients within a patient-centered medical home. Transl Behav Med. 2012;2(1):47–56.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Dobscha S, Corson K, Perrin NA, et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA. 2009;301(12):1242–52.

    Article  CAS  PubMed  Google Scholar 

  34. Elder N, Penn M, Pallerla H, et al. Provision of recommended chronic pain assessment and management in primary care: does patient-centered medical home (PCMH) recognition make a difference? JABFM. 2016;29(4):474–81.

    Article  PubMed  Google Scholar 

  35. Scascighini L, Toma V, Dober-Spielmann S, et al. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology (Oxford). 2008;47(5):670–8.

    Article  CAS  Google Scholar 

  36. Cartier J. A team-based approach to the care of depression in later life: where are we now? Psychiatr Clin N Am. 2013;36(4):651–60.

    Article  Google Scholar 

  37. Finley P, Rens HR, Pont JT, et al. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacother: J Hum Pharmacol Drug Ther. 2003;23(9):1175–85.

    Article  Google Scholar 

  38. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273(13):1026–31.

    Article  CAS  PubMed  Google Scholar 

  39. Katon W, Seelig M. Population-based care of depression: team care approaches to improving outcomes. J Occup Environ Med. 2008;50(4):459–67.

    Article  PubMed  Google Scholar 

  40. Katon W, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611–20.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Unützer J, Katon W, Williams JW, et al. Improving primary care for depression in late life: the design of a multicenter randomized trial. Med Care. 2001;39:785–99.

    Article  PubMed  Google Scholar 

  42. Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–45.

    Article  PubMed  Google Scholar 

  43. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative metaanalysis and review of longer-term outcomes. Arch Intern Med. 2006;166(21):2314–21.

    Article  PubMed  Google Scholar 

  44. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15(7):35–40.

    PubMed  Google Scholar 

  45. Schuetz B, Mann E, Everett W. Educating health professionals collaboratively for team-based primary care. Health Aff (Millwood). 2010;29(8):1476–80.

    Article  PubMed  Google Scholar 

  46. Sinsky C, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272–8.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21(6):23–9.

    PubMed  Google Scholar 

  48. Spinelli W. Physician and staff burnout in clinics. AAFP Scientific Assembly. San Diego; 2013.

    Google Scholar 

  49. Kottke T, Maciosek MV, Huebsch JA, et al. The financial impact of team-based care on primary care. Am J Manag Care. 2016;22(8):e283–e6.

    PubMed  Google Scholar 

  50. Wise H. The primary care team. Arch Intern Med. 1972;130:438–44.

    Article  CAS  PubMed  Google Scholar 

  51. Piatt G, Orchard TJ, Emerson S, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29(4):811–7.

    Article  PubMed  Google Scholar 

  52. Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective team-based health care. Inst Med. 2012.

    Google Scholar 

  53. Shoemaker S, Fuda KK, Parchman M, et al. Atlas of instruments to measure team-based primary care report. Rockville: Agency for Healthcare Research and Quality; 2014. Contract No.: AHRQ Publication No. 14-0063-EF

    Google Scholar 

  54. Bodenheimer T. Building teams in primary care: lessons learned. Oakland: California Healthcare Foundation; 2007.

    Google Scholar 

  55. Rodriquez H, Rogers WH, Marshall RE, et al. Multidisciplinary primary care teams: effects on the quality of clinician-patient interactions and organizational features of care. Med Care. 2007;45(1):19–27.

    Article  Google Scholar 

  56. Cramm JM, Nieboer AP. In the Netherlands, rich interaction among professionals conducting disease management led to better chronic care. Health Aff (Project Hope). 2012;31(11):2493–500.

    Article  Google Scholar 

  57. den Engelsen C, Soedamah-Muthu SS, Oosterheert NJ, Ballieux MJ, Rutten GE. Improved care of type 2 diabetes patients as a result of the introduction of a practice nurse: 2003–2007. Prim Care Diabetes. 2009;3(3):165–71.

    Article  Google Scholar 

  58. Keus SH, Oude Nijhuis LB, Nijkrake MJ, Bloem BR, Munneke M. Improving community healthcare for patients with Parkinson’s disease: the Dutch model. Parkinson’s Dis. 2012;2012:543426.

    CAS  Google Scholar 

  59. van der Marck MA, Munneke M, Mulleners W, Hoogerwaard EM, Borm GF, Overeem S, et al. Integrated multidisciplinary care in Parkinson’s disease: a non-randomised, controlled trial (IMPACT). Lancet Neurol. 2013;12(10):947–56.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Yee Lam MD, PhD .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Lam, Y. (2018). Team-Based Care. In: Daaleman, T., Helton, M. (eds) Chronic Illness Care. Springer, Cham. https://doi.org/10.1007/978-3-319-71812-5_32

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-71812-5_32

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-71811-8

  • Online ISBN: 978-3-319-71812-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics