A Physician's Role in Team-Based Patient Care

With Medicare-eligible citizens now representing the fastest-growing segment of the American population, it is more important than ever to find fresh approaches and new models of care to effectively manage the health and well-being of this group. Physicians, hospitals, and health plans need to find ways to work together if they are to provide patients with a higher quality of life and better care coordination while lowering overall healthcare costs. This is particularly true as it applies to low-income seniors, dual eligibles, and others with complex medical and social needs.

One tactic that is proving to be successful in this area is a high-intensity care-team approach outside of the hospital setting. Such an approach goes well beyond traditional care coordination and is consistent with a recent Avalere Health study, which reported that to be successful in today's environment, health plans and physicians need to not only focus on treating a person's medical condition but must also have strategies in place for managing a broad array of care needs across multiple settings.

For primary-care physicians, participation in a care-team program can ease the burden associated with the management of complex-care patients. It also provides a way to better manage the cost of these patients by optimizing their health and functional status, decreasing excess healthcare use, minimizing emergency department visits and other hospital utilization (including readmissions), and preventing long-term nursing home placement. 

Central to an effective care-team program is a support team overseen by a nurse practitioner and a social worker that work in concert with the primary-care physician to comprehensively address a patient's health conditions and achieve a patient's goal from the comfort of their own home. To be successful it is imperative that the team provides patients with healthcare education; medication management; and coordination of care between specialty physicians, the emergency department, hospitals, and a broad array of community support services.

In addition to better serving patients from a clinical and social standpoint, there are strategic reasons for primary-care physicians to consider programs such as these. For those physicians who participate in an accountable care organization (Medicare and/or commercial), take capitated risk, or serve a significant Medicare population (and are at risk for adverse events such as readmission and other penalties), this type of coordination can be a significant element in the move from fee-for-service to value-based pricing while generating cash flow and cost savings.

It is no wonder then that the Avalere study said that enrolling members into an effective care-transition or care-coordination program "can help … reduce their members' healthcare utilization and subsequently their spending." In a model presented in the study, Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care™  from Indiana University Medical Center produced annual savings for high-risk members of nearly $4,300 while producing a ROI for the health plan of 95 percent per year.

Physicians looking to participate in a care-team approach outside of the hospital should be sure that their program includes:

• In-home assessment and care management by a team of experts.

• Specific protocols to manage common geriatric conditions.

• Integrated EHR documentation.

• Web-based care management tracking.

• Integrated pharmacy, mental health, hospital, home health, and community-based services.

• Individualized care planning and implementation of a care plan consistent with the participant's goals.

• Frequent inter-professional team conferences.

• Nurse practitioner and social worker meetings with the primary-care physician.

• Ongoing care management and caregiver support.

• Protocols to ensure continuity and coordination of care including smooth transitions from one point on the healthcare continuum to another.

Older patients with chronic conditions and functional limitations require more medical services and social support than do their less complex or younger counterparts. And beyond their physical healthcare challenges, these patients often must deal with a host of socioeconomic stressors including low health literacy, limited access, fragmented healthcare, and poor communication and coordination of care.

The combination of all of these factors makes it imperative that physicians, hospitals, and health plans continue to look for even better ways to serve these citizens in need. By moving the traditional concept of care coordination to a new level, the entire healthcare system can be more efficient, more patient-centric and more responsive to improving the entire patient experience.

Steven Counsell, MD, is executive director of the GRACE Team Care program, Mary Elizabeth Mitchell professor and director of geriatrics at Indiana University School of Medicine, and president-elect of the American Geriatrics Society. E-mail him here.