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.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
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.
Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246–51.
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.
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.
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.
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 [Unpublished white paper]. 2010.
Wagner E. The role of patient care teams in chronic disease management. BMJ. 2000;320:569–72.
Wise H, Beckhard R, Rubin I, Kyte AL. Making health teams work. Cambridge, MA: Ballinger Publishing Co; 1974.
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.
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.
The Patient Centered Medical Home History. Seven core features, evidence and transformational change. Washington, DC: Robert Graham Center; 2007.
Wagner E, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;4:511–44.
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.
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.
Wagner E. Chronic disease management. What will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2–4.
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.
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.
Health Sciences Institute. 2017. Available from: http://www.healthsciences.org/Infographic-The-Costs-of-Chronic-Disease-Implications-for-Health-Care.
CDC. Team care approach for diabetes management. 2017. Available from: https://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide-team-care-approach.pdf.
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.
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.
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.
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.
Bellam N, Kelkar AA, Whellan DJ. Team-based care for managing cardiac vomorbidities in heart failure. Heart Fail Clin. 2015;11(3):407–17.
Creaser J, DePasquale EC, Vandenbogaart E, et al. Team-based care for outpatients with heart failure. Heart Fail Clin. 2015;11(3):379–405.
Wever-Pinzon O, Drakos SG, Fang JC. Team-based care for heart failure. Heart Fail Clin. 2015;11(3):467–77.
Jaarsma T. Inter-professional team approach to patients with heart failure. Heart. 2005;91(6):832–8.
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.
Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation. 2002;105:2861–6.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Katon W, Seelig M. Population-based care of depression: team care approaches to improving outcomes. J Occup Environ Med. 2008;50(4):459–67.
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.
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.
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.
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.
Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15(7):35–40.
Schuetz B, Mann E, Everett W. Educating health professionals collaboratively for team-based primary care. Health Aff (Millwood). 2010;29(8):1476–80.
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.
Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21(6):23–9.
Spinelli W. Physician and staff burnout in clinics. AAFP Scientific Assembly. San Diego; 2013.
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.
Wise H. The primary care team. Arch Intern Med. 1972;130:438–44.
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.
Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective team-based health care. Inst Med. 2012.
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
Bodenheimer T. Building teams in primary care: lessons learned. Oakland: California Healthcare Foundation; 2007.
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.
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.
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.
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.
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.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG
About this chapter
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)