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Team-based care in a medical neighborhood

Team-based care is based upon six guiding principles that influence the interactions between providers. These principles apply to all providers, with each provider integrating each principle into its day-to-day operations. The six principles are described below.

  1. Identify the best method for communication and your point person at the practice.
  2. Seek the best approach to sharing medical information. Some practices might prefer that you send them a fax with a specific cover page to catch their attention, while others might prefer a phone call. Some practices might have an electronic medical record that allows you to securely message them. It is also important to determine who on the team will be communicating with you regarding a patient’s care plan. Some prescribers might want you to contact them directly, while others might want you to contact their nurse or front desk staff.

    “Each practice that you deal with has a preference for how they like to communicate, so it’s helpful to talk to them and find out what they like. That way they won’t wind up with 10,000 faxes on their desk that they don’t have time to read.“– Community Pharmacist
  3. Identify the roles for all members of the care team.

    The care team includes the community pharmacist, pharmacy technician, prescriber, nurse, care manager, etc. Community pharmacist roles may vary based on the specific team needs, patient type, and reimbursement opportunities available.

    “I just think everybody has to understand what their role is and be open to having a multidisciplinary team and being okay with missing things and making mistakes every once in a while. We all do.” – Physician
    “And too, the primary care provider knows that we've already done the medicine part, but there are things that we cannot do, so I think it is knowing your role. And our role is medication, and sometimes there are living conditions that may or may not affect medication. So, we need to have our own separate roles, but then at the same time we need to recognize where they overlap, and to me that is the other piece that's huge” – Community Pharmacist
    “It really helps us to talk to that doctor and say, ‘What is your A1C goal for this patient?’ We can then meet with the patient one-on-one to really focus on adherence and lifestyle modifications, and we can say, ‘This is what we want your goal to be after three to six months.’ When we check—or have the doctor recheck—a patient’s A1C, we're able to say, ‘Hey, this is what happened.’ So it’s just basically an extension of what the doctor provides as far as goal setting. It's more like a health coaching kind of thing” – Community Pharmacist
  4. Measure impact and conduct continuous quality improvement.

    The impact of team-based care can be measured in a variety of ways, including:

    • Clinical outcomes (improved blood pressure control or decreased A1c levels)
    • Process metrics for a defined population (falls risk screening for patients ≥ 65 and on four or more unique medications)
    • Improvement in medication adherence

    Consider scheduling quarterly or annual meetings to review the measurements and determine a plan to improve outcomes going forward.

    “We know our collaboration with physicians and nurses is working when we see patients meet their goals. For example, we’ll talk to a doctor and ask about her goals for a patient. We then meet with the patient one-on-one to focus on adherence and lifestyle issues. We can also look at certain labs, such as hemoglobin A1c, to see if the patient is meeting the goal. We share our success stories with the physicians and nurses at the practice to let them know what we accomplished in a certain period of time.” – Community Pharmacist
  5. Determine resources needed by team members.

    Work with other team members to determine the resources needed. For example, primary care practices might need a patient’s adherence to prescribed medications, or they might request home delivery for a patient. Let team members know what you need to conduct patient care (i.e., medication changes, hospital discharge information).

    “We had a patient who was a poorly controlled diabetic. I kept augmenting insulin, and it didn’t really matter what I did because nothing was working. It turns out he wasn’t filling his diabetes medication except for when it was time for an office visit. He would fill them then so he could bring in his pill bottles and show me that he had his medication. The community pharmacy had access to his billing record, of course, so when I talked to them, we demystified a lot of things.” – Physician
  6. Communicate with patients.

    Let patients know that you work with other members of their care team. Encourage the prescriber or care managers to let their patients know you work together to improve their health.

    “We let our patients know that we work closely with their community pharmacist, especially when there’s a specific goal we’re working on. For example, if we’re trying to get a patient’s blood sugar down, then we tell the pharmacist what we’re trying to accomplish—and the patient knows that we do this. That way everyone is pulling in the same direction.” – Physician
  7. Identify shared goals.

    Schedule a face-to-face meeting with a local medical practice to determine shared goals. During this meeting, share your community pharmacy’s goals and identify the services you can offer to help the practice.

    “We took the time to sit down face-to-face and get to know each other. We talked about the services the pharmacy offered—and its goals—and then we realized that of course our goals align. We all want what’s best for our patients.” – Physician
An example

Bob is a 67-year-old man who has chronic obstructive pulmonary disease (COPD). He has been in the hospital for a COPD exacerbation and is being discharged today. This is his third hospitalization in two months.

The discussion that follows illustrates how his healthcare team works together to provide team-based care and prevent his rehospitalization.

Hospital
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During his hospital stay, Bob was prescribed a new maintenance medication for his COPD. The hospital sends a prescription for the new medication to the community pharmacy. Per an earlier agreement, the hospital also sends a copy of Bob’s discharge summary. Using the information on the discharge summary, the pharmacy performs a medication review to ensure that Bob is on the correct medication. The pharmacy also provides medication education as necessary.

Pharmacy
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When Bob goes to the pharmacy to pick up his medication, the pharmacist performs a comprehensive medication review (CMR) and discovers that Bob cannot afford his medication. She also finds out that Bob has been using a rescue inhaler multiple times a day instead of his maintenance inhaler. Additionally, Bob reveals that he does not own a car, which makes transportation to the pharmacy and to the doctor challenging.

Social services
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The community pharmacist refers Bob to a care manager who helps him fill out an application to receive extra help. The care manager will conduct home visits to ensure that Bob has everything he needs. She will also arrange transportation for follow-up appointments with his primary care provider (PCP) and his pulmonologist.

Primary care clinic
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The community pharmacist lets Bob know that she works with his care manager, primary care provider, and specialist to make sure that he receives the best care possible. She sends a message to Bob’s PCP to let him know Bob has been in the hospital for a COPD exacerbation and has started on a new medication. She lets his PCP know she already conducted a CMR, provided medication education for his new medication, reconciled his active medication list, and identified medication-related problems. She sends this list to the PCP’s nurse via electronic health record secure messaging. In previous meetings, it was determined that Bob’s PCP prefers this form of contact when communicating with patients.

Specialist
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The community pharmacist contacts Bob’s pulmonologist and provides a message similar to the one she shared with his PCP. That is, she tells the pulmonologist that she conducted a CMR, provided medication education for his new medication, reconciled Bob’s active medication list, and identified medication-related problems that pertain to the specialist.

When Bob visits his pulmonologist next week, the doctor will inform him that he has received an active medication list from Bob’s community pharmacist. This information will help the pulmonologist spend most of the appointment assessing Bob’s COPD.

Home
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Bob’s healthcare team monitors his hospital visits and notices that he has not been readmitted after 30 days. This exciting news suggests that their collaboration is working!