Value-based care is a team sport: How to optimize roles for better outcomes

Tammy Schaeffer: ©Plante Moran

As leaders of the care team, physicians rightfully take their role in driving patient outcomes very seriously. This is equally true when practices pursue value-based care. To succeed in these arrangements, physicians must continue to act as the “captain” of a patient’s care, however they also must leverage the skill sets of their full team to support early identification of conditions, care plan execution, and ongoing patient monitoring and treatment.

Leveraging the care team to their full potential can be a challenge. Many organizations place the entire responsibility for risk capture and patient management on physicians. Unfortunately, this not only overburdens even the most dedicated providers, it also results in missed diagnoses, insufficient documentation and risk capture, and suboptimal reimbursement.

Conversely, when every staff member works at the top of their license and shares responsibility for identifying, documenting, and managing patient conditions, it creates a collaborative, purpose-driven environment that enables reliable care management and promotes accurate risk capture and reimbursement. Practices that pursue this team-based approach also see greater staff satisfaction and retention because staff feel more connected to each other and fulfilled by their work.

Embracing a new model

It’s easy to say “work as a team” but to truly achieve the right level of collaboration, physician practices must rethink how they function. Approaching this in a methodical way can lead to lasting and sustainable success. Here are a few strategies to consider.

Conduct a role-based inventory.Before making changes, it is imperative to understand the work being done by each role. Taking the time to complete a thorough inventory will identify work that isn’t adding value and pinpoint who may have capacity to take on more responsibility. This review should span the entire care continuum, from appointment scheduling to patient checkout, and must include what happens in-between visits. During this review, practice leaders should think through what tasks could be handled differently for greater efficiency and effectiveness. For example, while a physician must diagnose a patient and develop the appropriate care plan, other qualified staff members can facilitate parts of the assessment and examination, calling out important information the physician should address when meeting with the patient. Similarly, the team member can collaborate with the provider and check on patients between visits to answer any questions, discuss concerns, and make sure a patient is following the care plan.

Involve physicians early on.Practice physicians must be at the table and engaged in any restructure or alignment activities from the outset. Provider insight is critical to these changes, especially the integration of evidence-based care. Physicians will also have key insights on what they should handle versus what may be supported by another team member. If providers don’t have confidence that things will get done well and in a timely fashion, they may try to manage everything on their own, which will stall a practice’s efforts towards greater collaboration and teamwork.

Depending on a practice’s size and current dynamics, it can be helpful to bring in an expert third party to facilitate an unbiased inventory and help identify areas that may be ideal for restructure. An outside resource can remain objective as they consider assorted perspectives and recommend the optimal structure based on the practice’s unique characteristics.

Accessibility is key. Accessibility is the greatest leading indicator of success in value-based care.Still, many practices struggle to help patients get the care they need when they need it. Using your staff to their full potential can assist with proactive risk identification, fostering a positive patient experience and enabling strong quality performance.

The move to quality starts at the front door. For example, when the patient arrives for an appointment, patient access staff can assess demographics, document preferred communication methods, assess social determinants of care, review insurance information, and check eligibility for payment programs the patient may not be aware of or is using. The team can also administer certain screenings, such as the PHQ-9 questionnaire, which assesses a patient's risk for mental health conditions like depression and anxiety.

After the patient’s appointment, staff can help schedule follow-up visits or get information about referrals, helping the patient navigate the next steps for additional care. Throughout these interactions, staff can get to know and develop a rapport with patients, increasing the likelihood that patients will reach out to the practice when they have a problem instead of waiting until the issue becomes an emergency that requires a hospital stay.

Care adherence is a team effort.Medical assistants serve as a liaison between patients and physicians. For instance, instead of physicians having to answer 15 patient messages during their lunch break, medical assistants can triage patient questions, answering those that are administrative and surfacing to the physician those questions that warrant the doctor’s attention. Medical assistants can also ensure that patients have the information they need before departure, facilitate patient education, provide medical supplies, and answer basic questions patients may have. They can also proactively reach out to high-risk patients between visits to check how things are going. During these interactions, medical assistants can ask patients whether they are taking their medications, check for side effects, provide education, and answer questions. This can help improve care plan adherence and avoid acute situations while building patient trust.

Standardizing workflows is foundational to optimal outcomes. If you don’t have a standard way to do a task, don’t expect a standard outcome. Practices should establish clear care processes and pathways to ensure that risk identification and care management tasks are performed by the right person at the right time. This is especially important for managing chronic conditions, such as diabetes, hypertension, congestive heart failure and COPD. For these conditions, practices should have systematic and standardized care pathways which outline team actions to facilitate strong condition management and clinical outcomes.

Document the new approach. We’ve all heard the phrase, “if it isn’t documented, it isn’t done.”This has never been more true than as practices optimize and standardize tasks and workflows. As practices develop new ways of working, they should document each step to ensure that everyone in the practice has a clear understanding of what they are supposed to handle, why it’s an essential function, when it should happen, and how it connects to everyone else’s work. If practices don’t document the new workflow, standard performance often doesn’t happen, allowing tasks to fall through the cracks and causing frustration for patients and staff—not to mention increasing risk.

Educate patients about the new model.Some patients may feel uneasy relying on staff members other than physicians to meet their needs. Clearly and intentionally communicating the purpose and value of each role—and how these functions seamlessly work together to ensure high-quality patient care—is crucial to help patients feel confident they’ll receive timely, knowledgeable assistance regardless of who they interact with at the practice.

When collaboration happens by design, practices see better outcomes

By approaching value-based care as a team sport, practices lay the foundation for better performance. This degree of collaboration doesn’t happen by accident. Physician practices must design roles and processes intentionally, ensuring everyone works at the top of their license and follows choreographed, evidence-based care pathways. Taking the time to methodically approach the work at hand will help the practice identify risk and manage care more effectively while fostering an environment where everyone is focused on achieving the same goals.

Tammy Schaeffer, RN, JD, is a principal at Plante Moran.