Care Teams and Workforce Guide

Providing effective population-based primary care requires a shift from provider-centric care towards the provision of care by a multidisciplinary team organized around patients and families as critical members of their own healthcare team.^[1] In this paradigm, team members contribute their unique skills and expertise to support whole-person healthcare for a panel of patients. Spreading the work of providing preventive, chronic and acute care across the care team requires each team member to work at the top of their license, and involves reimagining traditional roles and responsibilities.

See Building the Foundations for Population Health Management: Talking Points for Engagement for talking points to help engage care teams and stakeholders in understanding the bigger picture of how the new care team model and other changes supports the practice’s population health management transformation efforts.

Because this is not how all or even most practices operate, developing and maintaining a team approach to care requires practices to invest time and resources to:

1. Go deep on who does what.

As you start exploring team roles, you may find there are overlaps or duplications that can be removed or gaps that can be filled. Using a tool like this table below can help clarify who is responsible and accountable for clinical tasks on the core care team. A similar tool can be used to explore how tasks are managed among the expanded care team.

2. Create new workflows.

As clinical team members work differently together, mapping how patients and information move between team members becomes important. This is especially true if your team is adding new services or team members to address behavioral health needs or to screen for social needs, for example. Figuring out when screenings occur, who does them, where the results are entered, and who follows up will likely require workflow development and implementation in your EHR or population health management system. Building these workflows into your EHR enables teams to see what’s working and what’s not, and to bring data to quality improvement meetings to continue to adapt and improve team services. It is equally essential to thoroughly document and clearly communicate these new workflows to all team members. Without proper documentation and consistent communication, there's a risk that important steps may be missed or misunderstood, or forgotten which can undermine the effectiveness and sustainability of the changes.

See the PHMI webinar, Person-Centered Workflows: Strategies for Development and Sustainability, for examples and discussion of strategies for collaboratively designing, testing and implementing clinic workflows.

3. Invest in training.

As responsibilities shift from one person to another and workflows are reimagined, teams must assure staff know how to complete their responsibilities. At a minimum, practices can be transparent about what roles need to have specific demonstrated expertise and provide clinical oversight to ensure that is happening. For example, medical assistants may regularly start to take blood pressure. More broadly, there is significant effort in California and nationally to establish ongoing training for medical assistants and community health workers. Resources on these topics are discussed in On the Horizon section below, and will continue to be developed throughout the Population Health Management Initiative and posted publicly.

4. Make space and time to bolster teamwork, in addition to task work.

Much of the work described above is technical in nature and is where many feel most comfortable working, however high functioning teams need trust and psychological safety to perform at their best. Creative practices have recognized the importance of interpersonal relationships on the teams, making time for relationship building, and considering personalities in addition to skills in creating teams. More information and resources are below in the Going Deeper section below.

In addition to investing time and resources, informal and formal leaders and champions have an important role to play in both the technical aspects of care redesign, like understanding state regulations for scope of practice, as well as softer skills, like fostering a culture of curiosity for how roles can be reimagined. Engaged leadership underlies high performing primary care and drives the success of all transformational efforts, including redesigning care teams. Successful practices mobilize leadership on at least three levels:

• Executive leadership develops and shares a mission-driven strategic vision for change, and makes organizational investments in resourcing the change efforts.
• A clearly designated operational leader with well defined responsibility and authority guides the day-to-day efforts of creating operational change.
• Clinical and care team champions promote change with their peers by bringing attention, enthusiasm and direct experience to the operational change efforts.

As an initial step, organizational leaders should develop and share a clear and compelling vision for change, including an overview of:

• What: Clear explanations of the essential components of core and expanded care teams.
• Why: Alignment between care teams and organizational mission and priorities, for example, creates high functioning teams and provides the foundation for a variety of proactive schedule and panel management practices, such as daily schedule scrubbing and huddling. Alignment can increase productivity through the redesign of clinic workflows, collaborative approaches to care management, and development of new modes of patient access and enable care gap outreach calls to patients with chronic conditions.
• How: Anticipated process, timeline and training implications for creating core and expanded care teams.

Because tackling teams means changing how people see and do their daily work, leaders will need to engage people from multidisciplinary perspectives to share their best thinking, support them to work together to make it even better, and lean in to address concerns as they arise.