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COVID-19 Recovery: Team-Based Care Toolkit

This toolkit includes team-based resources that can help physicians, their teams, and their patients optimize team-based care in a pandemic/post-pandemic setting.

Funding for the COVID-19 Recovery Team-Based Care Toolkit was made possible by Pfizer, Inc.

 

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What Is Team-Based Care?

Team-based model of care strives to meet patient needs and preferences by actively engaging patients as full participants in their care, while encouraging all health care professionals to function to the full extent of their education, certification, and experience.

  • Health care teams are defined as two or more health care professionals who work collaboratively with patients and their caregivers to accomplish shared goals.
  • A health care team may involve a wide range of team members in various settings.
  • Potential members include physicians, nurses, pharmacists, social workers, trainees, patients and their families, and others identified as persons necessary to help achieve shared goals.

Resources

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

  • A New Approach to Making Your Doctor-Team More Productive - This article from the AAFP gives tips on how to create a productive clinical team. It explains how with proper training and delegation, your team can see more patients, deliver better care, and increase patient and staff satisfaction.
  • Keys to High Functioning Office Teams - This article from the AAFP focuses on tips including hiring more nurses or medical assistants and more effectively distributing work and responsibilities to create high functioning teams to revolutionize your practice.

 

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Steps to Optimal Team-Based Care Framework

  1. Foster mutual trust, physical, and psychological safety.
  2. Clarify roles and expectations.
  3. Practice effective communication.
  4. Track a set of shared measurable goals.

Resources

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 – Developed by participants from the IOM's Best Practices Innovation Collaborative, this discussion paper identifies key findings from health care literature and uses interviews with eleven teams located across the United States to clarify how these factors shape effective team-based care.
  • Huddles: Improve Office Efficiency in Mere Minutes - Daily gatherings of your care team can help you meet daily challenges. The American Academy of Family Physicians posted this article to help physicians identify when and how to conduct a team huddle.

 

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Discussing Team-Based Care with Patients

Patients, families, and other caregivers need a clear understanding of the roles of the interprofessional care team with explanations of which role will serve which purpose in their care. The health care team should provide information to patients, families, and other caregivers so they can make informed healthcare decisions in partnership with their care team.

Resources

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:

 

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Effectiveness of Team-Based Care in a Pandemic

The unprecedented global health crisis of the 2019 coronavirus outbreak has presented a unique opportunity for mass mobilization towards team-based care and collaboration in the health care space. In the past, teamwork in health care has been limited by power hierarchies. COVID-19 has leveled the playing field in some ways; no one has experience treating a public health emergency of this magnitude. Doctors, nurses, advanced practice practitioners, and other key figures on the frontline need to collaborate, communicate, innovate, problem solve, remove silos, and recognize that everyone is on the same team in a collective effort against the virus for the betterment of the patient.

(citation: https://patientengagementhit.com/features/how-coronavirus-sparked-industry-collaboration-team-based-care)

Resources

Access these resources on harnessing the power of team-based care and providing effective care in a pandemic and post-pandemic setting:

 

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Separate Triage Settings

Many members of the healthcare team will have a role to play in in assuring that the patient triage process is safe and efficient. It is essential that potential COVID-19 patients be triaged separately from those with non-COVID concerns in separate settings to reduce infection.

Resources

These resources can help your practice set up and manage separate triage areas.

  • COVID-19: An ACP Physician's Guide - This online learning activity is free to the public and provides a clinical overview of infection control and patient care guidance. Up to 10 CME credits are free to ACP members and provided at a nominal fee to non-members.
  • COVID-19 Telemedicine Risk Tier Assessment – This chart can help practices assess how to determine a patient's COVID-19 risk during a telemedicine visit.
  • Scripts for COVID-19 telephone triage – Use this script and accompanying decision algorithm and messages from the CDC when assessing possible COVID-19 patients over the phone.

 

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Safely Resuming Care

Safely resuming care during and post-COVID will require the effort of the entire team from front-office staff to community partners. It is essential to outline the job descriptions and roles of various team members (including clinic administrators) and develop appropriate workflows, checklists, and other documentation to ensure protocols are followed appropriately.

Resources

Access these practical resources to help your practice safely resume care.

  • Innovative Staffing Models - Implementing innovative staffing models will be key for your practice's COVID-19 recovery plan. Innovative staffing models help to ensure the safety of your office staff, offer flexible options for your staff in the time of a pandemic, help to identify core functions that can be done in the office versus remotely, and help you to prepare in the event of staff shortages due to staff or family member illness.
  • Sample Job Descriptions – This site includes job descriptions for contact tracer, contact tracing supervisor, case investigator, and care resource coordinator.
  • Sample Job Descriptions – This site includes opportunities and job descriptions from the University of Pennsylvania's Community Health Worker Program (IMPaCT).
  • Workflow modifications to ensure patient and clinician safety - Workflows and procedures should be evaluated for needed modifications to ensure the safety of patients and office staff by limiting contact and physical interactions between clinical and office staff and patients. Workflows should also maximize the value of the in-person visit. This resource provides practical suggestions to adjust your office workflows to ensure patient and clinician safety.
  • Preparing your office for re-opening – ambulatory infection control checklist - Your practice will need to implement infection control procedures to reduce risk of transmission from known or suspected COVID patients as well as asymptomatic or pre-symptomatic carriers. This checklist is designed to help your practice reduce risk and guard the safety of your patients and clinical and office staff.
  • COVID-19: Team and Human Factors to Improve Safety – This article discusses how human weaknesses impact individual clinicians and care teams in ways that could degrade patient safety, reduce quality of care, and increase risk for both patients with COVID-19 and the staff that care for them.
  • COVID-19 Contact Tracer Job Description Template – This CDC template includes an introduction to case investigation, a position summary, essential functions, work requirements, and qualifications for a typical contact tracer job.

 

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Managing Transitions of Care for Post-Acute COVID Patients

As patients recover from acute COVID-19 infection, it is imperative that their care team works collaboratively to manage the various transitions of care they will face as they move from the hospital to home or to a long-term care facility.

Resources

Access these resources to help manage transitions of care for patients moving from the hospital to home or to a long-term care facility.

 

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Using Telehealth to Manage High-Risk Chronic Conditions

Health care teams can use telehealth to safely and effectively manage patient populations with chronic conditions during the pandemic understanding that there is still a need for in-person care. Access these resources designed to help teams optimize telehealth and identify where and how patients with chronic conditions can safely receive in person care when necessary.

Resources

Access these resources on optimizing telehealth, remote patient monitoring, and identifying where and how patients should receive in-person care:

 

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Informing Patients about Changes in Practice

The healthcare team should communicate with patients, families, and other caregivers about changes they are making in the practice to promote transparency and ensure patients feel safe and confident in returning to care.

Resources

Use these resources to inform and educate patients and their caregivers about changes they may encounter when returning for care.

 

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Sustaining Teams and Positive Changes

Psychological and physical safety is paramount. A lack of PPE and job loss are negatives that have come from COVID-19. In addition, physicians and their team members may feel resistant to integrating team-based care models. However, these models can help reduce burnout and sustain teams in the long term. In addition to acknowledging challenges, it is important to focus on the bright spots that have come out of the coronavirus pandemic (e.g., telehealth, pay/reimbursement), what has worked well, and how to incorporate those into the workflows post-COVID.

Resources

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 fulfillment and well-being.
  • Team-based Care and Flexible, Adaptable Leadership - Effective team-based care and leadership support is critical to helping your practice manage the unprecedented challenges of the COVID-19 pandemic. This resource provides a menu of recommendations to help you develop a plan for effective team-based communication and leadership in your practice.
  • Addressing Postpandemic Clinician Mental Health - The COVID-19 pandemic presents unique challenges that surpass those of previous pandemics, suggesting a significant mental health toll on clinicians. Long-term, proactive individual, organizational, and societal infrastructures for clinician mental health support are needed to mitigate the psychological costs of providing care during the COVID-19 pandemic.
  • Pandemic Workforce Well-Being: A Comprehensive Toolkit for Supporting Our Own During COVID-19 – This toolkit from Mount Sinai covers a variety of approaches to addressing the basic, psychosocial, and mental health needs of health care workers on the front lines of the pandemic.
  • Implementing Optimal Team-Based Care to Reduce Clinician Burnout – This article from the National Academy of Medicine discusses features of successful health care teams, reviews existing evidence linking high-functioning teams to increased clinician well-being, and recommends strategies to overcome barriers to optimal team-based care.

 

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Emerging Models of Team-Based Care

Real-life examples of successful team-based care during COVID-19 are starting to emerge from practices around the country. These examples showcase ways in which team-based care involving nurse practitioners, physicians' assistants, pharmacists, and others are working together with patients and caregivers together during the pandemic.

Resources