In this post, we put forth a social compact intended to define the reciprocal obligations of health care professionals, patients and society that are necessary to achieve truly patient-centered, team-based care. The compact and recommendations were developed from a working group formed at the March 2010 invitational conference co-sponsored by the American Board of Internal Medicine Foundation (ABIMF) and the American Academy of Nursing (AAN). These groups and the conference invitees represent constituencies crucial to implementing team-based care. The recommended compact moves beyond most of the writings about team-based care by the explicit inclusion of principles related to the patient and family as central members of the team.
Interprofessional team-based care is gaining momentum as a strategy to improve outcomes, continuity and effectiveness of health care from primary care to acute, hospital-based tertiary settings. This renewed interest and emphasis on interprofessional collaboration has its roots in several documents from an earlier era of health care reform. Over a decade ago, the Tavistock Group put forth shared ethical principles for health care that emphasized rights and responsibilities of both health care professionals and patients in shaping care. Shortly thereafter, the Institute of Medicine challenged the health professions to put patients at the center and in control of their health care.
More recently, the World Health Organization (WHO) reaffirmed its support for team-based care that puts patients in the center of care in order to achieve true primary health care in any nation. WHO further asserts that every health care worker should be prepared to participate as a full member of teams, a position affirmed by the Interprofessional Education Collaborative Expert Panel. Despite this growing momentum for team-based, patient-centered care, we have not achieved it, nor have we achieved true control by patients of their health care.
There is growing evidence that team-based care in both primary care and acute care settings is valued by patients and providers, is linked to improved quality and safety of care, and to improved health and functioning in those who have a chronic illness. The 2010 passage of the Patient Protection and Affordable Care Act (PPACA) offers an outstanding incentive to move forward with team-based, patient-centered care.
What Is Team-Based Care?
We accept the following definition of team-based care:
The provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, efficient and equitable. (Naylor MD, Coburn KD, Kurtzman ET, et al. Team-Based Primary Care for Chronically Ill Adults: State of the Science. Advancing Team-Based Care. Philadelphia, PA: American Board of Internal Medicine Foundation, 2010)
This definition is consistent with the World Health Organization (WHO) principles of primary health care: care that focuses on health needs, is based in an enduring personal relationship, is comprehensive and continuous, takes responsibility for health beyond the confines of a specific episode, and sees patients as partners in managing health. The definition also implicitly recognizes that although ambulatory primary health care affords many opportunities for team-based care, care provided for many acute or subacute conditions inside and outside of hospitals also benefits from a team-based approach.
The WHO principles reflect characteristics of effective ambulatory teams, as recently reviewed by Naylor and others. These characteristics include structure (team composition; culture); team dynamics (mutual goal setting; collaboration); and team communication. Carpiano et al also identify tenacity as essential to patient-centered prevention care.
The planks of this compact are built upon competencies produced by numerous interprofessional collaborations over the last decade. Although these competency statements have encouraged patient-centered care, they have not called for patients to be actively engaged as members of health care teams, as this compact does.
We use the term ‘patient’ in this compact quite broadly to encompass individual patients, extended families or other social groups, or even a small community group. Thus a team might include two providers and a single patient, or wider circles of providers and recipients of care.
Principles of the Compact: Obligations of Health Care Professionals to Society
Medicine, nursing, social work and other health care professions comprise what Sullivan describes as civic professions – those who make a “public pledge to deploy “technical expertise and judgment not only skillfully but also for public-regarding ends and in a public-regarding way”. Explicating this social compact is a means to make public the obligations of health care professionals to society.
- Professionals must place the patient at the center of all health care teams. This means that patients play an active role in decision-making related to all aspects of their care, and that professional team members have a full understanding of their patients’ histories and needs and help manage their care effectively. Team members should be recruited based on the needs and preferences of the patient, and to the extent possible, the care patients receive should be organized around those needs and preferences.
- Professionals must ensure that patients understand their role on the team. Health care professionals have an obligation both to ensure that patients—to whom the team concept may well seem foreign— understand their own roles and responsibilities, and have the support necessary to enable joint decision-making. For example, patients should be helped to understand from the team’s inception their responsibility for interacting with the care team and helping to manage their own care and well-being. This is essential not only to creating a climate of trust, mutual respect and accountability, but also to achieving the best possible health outcomes. Indeed, there is growing evidence that healing and prevention flourish when there is mutual respect and shared decision making among the care providers and recipients. For both patients and health care teams, shared decision-making is often a significant paradigm shift which may be more effective if preceded by an intentional process. Such a process can include an invitation into a collaborative relationship and an affirmation by teams and patients that the goal of the relationship is to provide the support necessary to allow patients to take responsibility for their health care decisions. If the institutional culture where the team operates does not expect and reinforce full patient engagement, it will only be a minority of confident, well-prepared patients who can engage as full partners with an equal say in decision-making and treatment implementation.
- Health professionals must continuously develop not only their clinical and caregiving skills, but also the competencies essential to collaborative work and practice. These competencies include clarity about individual roles and responsibilities and those of other team members, flexibility, clear and open communication, collective ownership of goals and reflection on process. (See Figure 1.) Health care teams must first commit, after a robust process, to the notion that, where health care is effective, patients are – with expert assistance from their care teams – making decisions for themselves, taking responsibility for their own health and health care. Each team member has an important role to play and relevant expertise to offer. As such, team members are obligated to actively engage in decision-making to ensure that care decisions benefit from their expertise. The failure to do so can have highly negative consequences; indeed, poor communication among caregivers is one of the top causes of patient and caregiver frustration, lost time and medical errors.
- Professional regulatory organizations must emphasize team-based competencies. Through the competencies they define and measure, professional regulatory organizations play a crucial role in shaping how care is delivered and received. These organizations must stress the value of teams and find ways to measure professionals’ abilities to work through teams to facilitate effective care.
- Members of care teams must work with their leadership to improve the structure and culture of their organizations. An organization’s context (e.g., organizational structure, hierarchy, rewards) has an important effect on team functioning. This is particularly important in team processes such as communication, leadership, decision-making, psychosocial traits (e.g. cohesion, norms) and task design (e.g. team composition, autonomy, interdependence).
Finally, as noted earlier, the rights and responsibilities outlined in this compact are equally applicable to hospital-based care, as evident in a recent statement from the Hospital Care Collaborative. That multi-stakeholder group has emphasized the importance of, among other things, recognizing the contributions of various team members, clearly delineating responsibilities and providing care through non-hierarchical relationships.
FIGURE 1 (click to enlarge)
Principles of the Compact: Obligations of Society to Health Care Professionals
- Patients must play an active role in their own care. If patients are to be included as team members, they must take responsibility for playing an active role in making decisions about their care. Principles of shared decision-making as a key component of patient engagement have recently been defined and described by the Center for Advancing Health. Engagement is defined as “actions individuals must take to obtain the greatest benefit from the health care services available to them.” Rather than being passively ‘compliant,’ the engaged person is actively involved in a process “through which he harmonizes robust information and professional advice with his own needs, preferences and abilities to prevent, manage and cure disease.” The Center’s document outlines a number of patient behaviors that are central to active engagement, such as skills in seeking health care and appropriate payment mechanisms, learning about treatment and prevention options and appropriate self-care monitoring and treatment management. The document also outlines key components of successful communication with health care teams. It does not, however, address how institutions and teams need to change to help patients develop these skills.
- Society must prioritize and devote resources to health professions training in settings that teach and model effective team-based care. If we expect health care professionals to work together on teams, we must provide them with the tools they need to do so effectively. Until now, the health professions have not typically promoted team-based care or the full incorporation of patients as team members in their education and training efforts. Few professionals are explicitly taught skills designed to empower and engage patients, or to work collaboratively with members of other health professions. At best, health professions are trained to orchestrate care. That must change, with those responsible for the content of pre-licensure and continuing education programs including guidance on team-based care within the curriculum.
- Payment/Reimbursement systems must support team-based care. If society wants to foster team-based care, we must have a reimbursement system that supports and incentivizes it. It should accord with the payment reform principles crafted under the auspices of the ABIM Foundation in 2009 and endorsed by a wide range of physician groups, consumer organizations, and others: “Payment systems should reward practices for oversight and coordination of care plans, including transitions from or between institutions, collection and review of data from consulting providers and institutions, phone and email consultations with multiple providers, and patient education, counseling and disease management.” These principles are consistent with recommendations from the Institute of Medicine that include advanced practice nurses in such teams.
Changing from our decades-old models of independent practitioners who ‘see’ patients to interdependent professionals and patients who set goals and coordinate treatments together will not be an easy task. Our payment systems, our cultures of being professionals and being patients, and our educational systems foster the old model. As reflected in the compact, educators, professionals and patients all must change significantly in order for team-based care to thrive. Health professionals must embrace a collaborative model of care delivery. Health professions educators must create new curriculum that fosters interprofessional, patient-centered teams. And patients – past, present and future, and those who love and support them –must summon the courage and self-discipline to enter into a real partnership for their health and health care.
Our intent with this social compact is to foster discussion and ultimately persuade all relevant stakeholders to incorporate these principles into all care settings in order to create high value care relationships and highest quality outcomes. We also want to stimulate the health professions to fully incorporate patient engagement into health professions education at all levels, and to invite groups who represent patients’ interests to explore collaborations to prepare the ground for true team based care. We invite your commentary and debate.