"If you have health, you probably will be happy, and if you have health and happiness, you have all the wealth you need, even if it is not all you want."
~Elbert Hubbard
American writer, publisher, artist, and philosopher

What’s ‘team-based care’?

All team-based care delivery models share common features that are key to their success in generating significant cost savings, driving continuous improvement in care quality, and winning new records in patient satisfaction. They are built on strengthening the role of the family physician or another qualified provider who works in a close relationship with the patient and a multi-disciplinary team to coordinate and deliver high-quality patient care across all care settings. All engage active patient participation in decision-making, and all enhance patient access to primary care with approaches like same-day appointments and extended daily and weekend hours.

In recent years, there has been a proliferation of care delivery models that could be described as “team-based care.” Other names for this model include patient-centered medical home, advanced practice primary care, health home, direct primary care, community health teams, person-centered health care home and primary care home, among others. We believe these variants have common structures and goals.  HEART believes the variants of the models described below that contain HEART-recommended Best Practice Standards for Team-based Care [link to recommendations] hold the greatest promise for achieving our shared goals of improved care quality and reduced cost.

Please note, however, that not all variants of these models are Team-based or incorporate HEART-recommended Best Practice Standards. For example, some Health Homes do not operate in teams and do not offer coordinated care. Similarly, not all Direct Primary Care practices are Direct Primary Care Medical Homes. Consequently, HEART does not endorse them.

The Patient Centered Medical Home, also called the “Advanced Primary Care Practice”:  In this model, patients establish an ongoing relationship with a primary care provider working as a member of a physician-led team of allied health professionals that provides or coordinates all aspects of preventive, acute and chronic care needs of patients.  PCMH, like other Team-based care models, utilizes health information technology and relies on best available evidence.  An APCP or PCMH doctor’s office is a re-designed practice that has shifted from focusing on episodic treatment of disease to the holistic care of a patient. Practices are paid a per-member per-month fee for intensive primary care interventions such as coaching chronically ill patients on effective self-care, working with patients to develop an individual care plan, coordinating with a patient’s other doctors and specialists, using technology to track and coordinate patient care, managing hospital transitions and utilizing resources outside the physician office to help patients stay healthy and navigate the health care system.

The Direct Primary Care Medical Home (DPCMH):  This model is much like the PCMH in its focus on patient-centered care and its emphasis on the prevention and management of chronic disease. Rather than relying on physician management of a team of allied health professionals to coordinate patient care, the DPCMH reduces physician patient panel sizes to enable the physician more time to develop a personal relationship with the patient and to participate more fully in delivering and coordinating the patients care. In the typical DPCMH office visit is 30-60 minutes, supplemented with scheduled phone visits, and e-communications. Like the PCMH, the DPCMH has extended and weekend hours and DPCMH physicians assume personal responsibility for coordinating care throughout all care settings. The direct practice model operates on the premises that productive physician-patient relationships take time to develop and that savings are garnered through physician effectiveness in motivating healthy changes in patient behavior that reduce patient demand for utilization of downstream services.  DPCMH payments are typically based on a fixed monthly “subscription” which covers comprehensive primary care services. (reference:  http://www.nytimes.com/2012/05/27/opinion/sunday/lets-be-less-productive.html)

Of Note: the Affordable Care Act recognizes the merit of the DPCMH at the core of a comprehensive insurance model as an option for delivery of patient-centered, coordinated health care in Part I, Section 1301 (a) (3) TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME PLANS, when it states:

The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.

Community Health Teams:  SEC. 3502. of the Affordable Care Act directs the Secretary of HHS to establish a program with eligible entities to establish community-based interdisciplinary, inter-professional teams (referred to as ‘‘health teams’’ ). Such teams may include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers (including substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians’ assistants. The health team shall establish contractual agreements with primary care providers to provide support services to support patient-centered medical homes,  defined as a mode of care that includes: a personal physician; whole person orientation; coordinated and integrated care; safe and high-quality care through evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements; expanded access to care; and payment that recognizes added value from additional components of patient-centered care.

Health Home: In this model, caregivers communicate primarily through a “care manager” so that a patient's needs are addressed comprehensively, access to needed services is facilitated, and patients not needing emergency care stay out of the emergency room and out of the hospital. As with the PCMH model, duplication of medical services is kept to a minimum through the sharing of electronic medical records. In the Health Homes, services are provided through a coordinated network of community-based organizations. The ACA defines the health home to mean “a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by an eligible individual with chronic conditions to provide health home services.”

Implemented correctly, all these models can satisfy HEART’s recommended Best Practice Standards and can be designed to produce the following important functional objectives:

a)  Provides Patient-centered Care – Engages the patient collaboratively with the provider in developing and adhering to a personal health plan that incorporates evidence-based, clinically recommended care, while reflecting patient lifestyle and preferences;

b) Invests Primary Care Provider with Responsibility for Coordination of Overall Patient Care throughout All Care Settings; and

c)  Supports patient adherence to her/his personal health plan, which is designed with emphasis on effective prevention and/or management of chronic disease conditions.

Tera Clizbe for Team Health Care


Dr. Carla Kakutani for Team Health Care


Bill Remak for Team Health Care