Team-Based Care Toolkit

Access these resources to help you define the team and understand general principals behind team-based care:

• Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit - The Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit provides information and resources on team-based care, the role of each team member, and sample huddle strategies. 
• Creating Patient-centered Team-based Primary Care – A proposed blueprint for patient-centered team-based care and strategies to provide patient-centered team-based care.

Access these resources to help build this framework and ensure clinical and administrative systems support team members in their defined work:

• IOM Core Principles & Values of Effective Team-Based Health Care – This discussion paper presents basic principles and personal values that characterize interprofessional team-based care. Developed by individual participants from the IOM’s Best Practices Innovation Collaborative, the authors identified key findings from health care literature, and used interviews with eleven teams located across the United States to clarify how these factors shape effective team-based care.
• Team-Based Care – This module from the AMA Steps Forward explores how to improve patient care and team engagement through collaboration and streamlined processes. It will help you define elements that constitute the model of team-based care, describe how to implement team-based care in your practice, and identify benefits of implementing team-based care in your practice.
• Advancing Team Culture: Workforce Effectiveness During COVID-19 and Beyond – This playbook from Vizient sheds light on significant developments in clinical teamwork during 2020 and shares proven strategies for fostering effective teams.
• Implementing High-Quality Primary Care: Rebuilding the Foundation of Healthcare – Chapter 6 of this report from the National Academy of Medicine, entitled “Designing Interprofessional Teams and Preparing the Future Primary Care Workforce”, focuses on key design elements of interprofessional teams and highlights the roles that extended care team members can play in delivering high-quality primary care.

The resources below may help you with your decision to add an NP or PA to your team or more effectively incorporate the APP’s on your team:  

• NPs vs PAs; What’s the Difference? - This short article summarizes how NPs and PAs are alike and how they are different. It covers differences in the focus of their education, certification and licensure, and in state law mandating physician involvement in practice. It even includes a handy set of key questions to ask prior to hiring an APP.
• PAs & NPs: Similarities and Differences – This infographic presents the similarities and differences between NPs and PAs in an easy-to-read infographic.
• Physician Assistant Scope of Practice - This state law chart from the AMA outlines several aspects of state laws regulating physician assistant practice including prescriptive authority, requirements for collaborative or supervisory arrangements, regulation, and scope of practice determination.
• PA Scope of Practice – This resource from the AAPA explains more about the scope of practice of PAs.
• Nurse Practitioner Practice Authority – This state law chart from the AMA outlines​ nurse practitioner practice authority by state.
• PAs and Team Practice - This resource from the AAPA highlights the important role of PAs in team practice.

• Clinician Well-Being at Virginia Mason Kirkland Medical Center: A Case Study - This case study provides an overview of initiatives that support well-being and reduce burnout in clinicians who work at the Virginia Mason Kirkland Medical Center. The purpose of this case study is to provide readers with tangible information to understand how Kirkland Medical Center has adopted programs and policies that support wellbeing. These include allowing clinicians to practice to the full extent of their education and training and standardizing roles for medical assistants.
  • Webinar Video Recording of the Virginia Mason Kirkland Medical Center case study
• Building Teams in Primary Care: 15 Case Studies – This set of case studies explore a variety of practices who successfully implemented teams. Case 11 (page 36-40) specifically addresses the use of physician assistants and nurse practitioners into Harvard Vanguard Medical Associates, a large multi-specialty group practice in the Boston metropolitan area, to successfully manage chronic conditions.
  • Watch this 3-minute video that describes how they have implemented effective team based primary care at Emory Patient Centered Primary Care.
• Team-Based Care – This TCPi Team-Based Care power pack highlights Union Square Family Health Center, a Family Medicine site of the Cambridge Health Alliance in Boston, MA and how they successfully implemented a team-based care model as a sustainable solution to overwork.

• Video on Interdisciplinary Rounds – This video features a patient care team at Christiana Care's Wilmington Hospital intensive care unit that demonstrates the patient and family centered care practice of interdisciplinary rounds at the bedside.
• Leveraging Advanced Practice Providers during a Crisis: Lessons Learned from Top Healthcare Systems – This white paper from the American College of Healthcare Executives shares crisis strategies from APP leadership across the nation during the COVID-19 pandemic and showcases the innovative ways APPs met unprecedented demands.
• Integrating Advanced Practice Providers into value based care strategies: One organization’s journey to achieve success through interprofessional collaboration – This case study from the Journal of Interprofessional Education and Practice showcases an urban academic pediatric hospital that enhanced the use of Advanced Practice Providers (APPs) to optimize care.

These job descriptions and other hiring resources can help you facilitate decisions about which patients see which team members, and the best ways to optimize outcomes while having everyone work at the top of their scope.

• The Business Case for Hiring a Nurse Practitioner – this article outlines estimated expenses, potential revenue generation and potential profits to expect after the addition of an NP to your practice.
• Sample APRN Job Description – Sample APRN job description for an outpatient internal medicine clinic.
• Sample Physician Assistant Job Description – Sample PA job description for an inpatient setting.
• Sample Core and Specialty Privileges for PAs – Resource from the AAPA.
• PAs: Credentialing, Privileging, and Assessing Competency (FPPE & OPPE) – Resource from the AAPA.
• Third-Party Reimbursement for PAs – Resource from the AAPA.
• Strategies for Recruiting NPs and PAs - In this article from the ACP Hospitalist, two hospitalists share their program’s model for outreach, screening, and interviews.

The following resources can help patients understand the different roles that make up the interprofessional health care team and how they might interact with each:

• Who’s Who on the Healthcare Team: An Interdisciplinary Approach - This article provides a brief introduction to the educational background and role of the different professionals a patient might typically encounter in a hospital.
• Your Health Care Team - This article provides a brief description of the roles of the different professionals a patient might typically encounter in a hospital.
• Your PA Can Handle It – This patient-facing resource explains more about the physician assistant role on the healthcare team.

These resources address how team-based care can reduce burnout and how to sustain team-based care models in the long term.

• ACP’s Well-being and Professional Fulfillment Resources – These resources from ACP can help physicians and their teams reduce burnout and find ways to enhance professional satisfaction and wellbeing.
• Team-based Care and Flexible, Adaptable Leadership - This menu of recommendations can help you get started with developing a plan for effective team-based communication and leadership in your practice.
• Physician Assistant Burnout Resources – These resources from the AAPA help support the well-being and professional satisfaction of physician assistants.
• Mini but Mighty Appreciative Inquiry  – Appreciative Inquiry is an organizational development model that takes a positive approach to systems change. This webinar, developed by Kerri Palamara, MD, FACP, Director of the Center for Physician Well-being at Massachusetts General Hospital and Physician Coaching Services Lead for ACP, and presented by North Carolina Well-being Champion Marion McCrary, MD, FACP, guides you through using the AI approach in your practice and teaching others to do the same.