Care Teams and Workforce Guide

In response to the evidence that healthcare has a relatively narrow effect on health outcomes in comparison to social and structural factors, there has been an explosion of interest in broadening the provisions of primary care from the traditional approach inside the walls of a clinic to a more expansive, collaborative and community-based model.^[1] Expanding primary care outside the walls of the clinic can include a range of strategies, including:

• Deploying community health workers, members of the peer workforce, or other lay health promotion roles into community settings to engage people in health education, health promotion and healthcare engagement activities.^[2][3][4][5]
• Partnering with community-based organizations to provide services and resources to address health-related social needs.^[6]
• Rethinking the delivery of clinical services to include home visits for people who are medically complex, frail or otherwise homebound or home-limited.^[7]
• Moving from delivering community care to building community power through healthcare provider involvement in community organizing and activation efforts.^[8]

Although interest in expanding the premise of primary care has been building for years, this movement is picking up pace as the Centers for Medicare and Medicaid Services (CMS) offer new opportunities for more flexible funding and delivery of care. For healthcare providers in California, the CalAIM waiver, which is intended to drive transformation in Medi-Cal, creates an exciting set of opportunities to receive funding for delivering whole-person care in new ways. If you are a California provider interested in expanding care outside of the walls of your clinic, read through all the opportunities described on the CalAIM Initiatives website.

Here are a few key options to consider for expanding care for populations needing extra support:

• Community Supports are flexible benefits offered by managed care plans for eligible members who have a medical necessity for support relating to housing, recovery from a health event or condition, caregiving, food, and environmental adaptation or remediation, such as installation of grab bars or ramps or remediation of housing conditions that are aggravating asthma.
• Enhanced Care Management provides care management support for eligible Medi-Cal members who have complex medical, behavioral or social health needs. For enrolled members, care managers are able to meet people anywhere in the community, and provide intensive support and coordination to facilitate engagement in health and health-related services.
• Justice-Involved individuals, which includes anyone currently or formerly incarcerated in a jail, youth correctional facility or prison, are at much higher risk for serious health problems than the general public. California’s trailblazing efforts to support the justice-involved population creates an opportunity to offer targeted Medicaid services to eligible populations for up to 90 days prior to release, with the goal of reducing their health risks and improving their transition back to the community.

In addition to these CalAIM specific opportunities, there has been a range of innovations pushing the boundaries of primary care into the community in recent years. As you consider new ways of working with patients, families and community organizations to improve health and well-being, make sure that you are carefully thinking about issues of equity. This will help ensure that you are engaging those who might be hardest to reach, considering personal and organizational power dynamics to optimize participation and contribution for those who are historically disempowered, and collaboratively designing your approach with all of the relevant stakeholders so that you can maximize the value and impact of your programs.

The rapid growth in virtual care prompted by the COVID-19 pandemic offers an additional set of opportunities for your care team to deliver care outside the walls of your clinic. Although telehealth in various forms has existed for a century, uptake prior to the pandemic was relatively slow due to regulatory and reimbursement issues, as well as technology and implementation challenges for both patients and providers.^[9] Although the pandemic is receding, virtual care continues to be a critical strategy for providing cost-effective, convenient access to care.^[10] Nonetheless, an effective and sustainable approach to telehealth requires thorough consideration of the equity implications and strong implementation planning for virtual care.

Despite the value of enhanced flexibility to access healthcare without visiting a clinic, these benefits do not accrue equally to all populations. Some patients might have challenges connecting to telehealth services due to both personal and geographic constraints, such as not being able to afford an internet-enabled device or living in a rural area without high-speed internet. Engaging in telehealth may also be especially challenging for people with low digital or health literacy, limited English proficiency, or cultural norms and beliefs that create a preference for in-person care.^[11][12][13] Although telehealth does offer the potential to expand access for patients who are facing transportation, childcare or other logistical challenges to visiting a healthcare facility for in-person care, your approach must be carefully designed with equity considerations at the fore to avoid reinforcing or deepening health disparities.

In addition to equity considerations, there are a range of implementation strategies that can help improve your approach to virtual care:

1. Don’t expect your technology to do all the work for you. Even though you may have good technology systems in place, you need humans to change their behavior to make virtual care viable. Make sure that you have a change management strategy with appropriate clinical champions to support the adoption of a new approach.^[14]
2. Explore options for centralizing telehealth services versus retaining all responsibilities for virtual care at the local team level. There is not a single right answer to this question, so you will need to use local data and contextual factors to develop an approach that makes sense in your setting.^[15]
3. Be prepared to invest in training and process improvement to ensure that your virtual care workflows are acceptable to both patients and workforce members.^[16]
4. Study your results. In order to ensure that virtual care is not compromising equity or outcomes, develop your organizational capabilities to monitor telehealth engagement and health outcomes at the patient and population level.^[17]

The American Medical Association’s StepsForward module on Telemedicine and Team-Based Care describes models for telemedicine with example workflows based on a practice’s experience to date. It also includes a guide for considerations to help the core team determine if an in-person or a virtual visit is warranted.

Although there have been some early publications making recommendations for integrated primary care teams who shifted rapidly to a virtual approach because of the pandemic, there is still a lot to learn about optimizing teamwork for virtual care.^[18] Early recommendations focus on enhancing:

1. Coordination, including both implicit and explicit communication to enhance role clarity, sequencing of interdependent tasks, and the use of ongoing status updates and structured debriefs to check and adjust your approach.
2. Cooperation, with a focus on building trust to improve team performance. Existing research suggests that documentation of team communication and interactions supports trust and cooperation on virtual teams. Try out a range of documentation approaches while, of course, protecting privacy and compliance to ensure the appropriate exchange of information between team members, which may have previously happened in a conversation in the hall.
3. Cognition, with an emphasis on team cognition or a shared mental model of how the team collaborates. Team cognition may be well supported by establishing clear goals and investing in cross-training to ensure that all team members understand relevant roles, policies and procedures.
4. . Communication, including both formal and informal modes, to address both the critical elements of information exchange needed to provide patient care, as well as the informal communications that build trusting and friendly relationships between team members. Closed loop communication might be especially important for communicating the resolution to urgent issues or critical moments of vulnerability for a patient.^[19]

For both patients and providers, there is undoubtedly still a lot to learn about providing high-quality, equitable, team-based virtual care. For ongoing resources and support for telehealth implementation, check out the National Consortium of Telehealth Resource Centers, the Telehealth Center of Excellence, and the National Center for Telehealth Education and Research.