Collaboration in Practice

Executive Summary
Introduction
Quality, efficiency, and value are necessary characteristics of our evolving health care system. Team-based care will work toward the Triple Aim of 1) improving the experience of care of individuals and families; 2) improving the health of populations; and 3) lowering per capita costs. It also should respond to emerging demands and reduce undue burdens on health care providers. Team-based care has the ability to more effectively meet the core expectations of the health care system proposed by the Institute of Medicine. These expectations require that care be safe, effective, patient centered, timely, efficient, and equitable. This report outlines a mechanism that all specialties and practices can use to achieve these expectations.
The report was written by the interprofessional Task Force on Collaborative Practice and is intended to appeal to multiple specialties (eg, internal medicine, pediatrics, family medicine, and women’s health) and professions (eg, nurse practitioners, certified nurse–midwives/certified midwives, physician assistants, physicians, clinical pharmacists, and advanced practice registered nurses). This document provides a framework for organizations or practices across all specialties to develop team-based care. In doing so, it offers a map to help practices navigate the increasingly complex and continuously evolving health care system. The guidance presented is a result of the task force’s work and is based on current evidence and expert consensus. The task force challenges and welcomes all medical specialties to gather additional data on how and what types of team-based care best accomplish the Triple Aim and the Institute of Medicine’s expectations of health care.
Why is the American College of Obstetricians and Gynecologists taking the lead on this report?
The American College of Obstetricians and Gynecologists (ACOG) felt it was critical that obstetrician–gynecologists take the lead in bringing these diverse but integral specialties and disciplines together to craft a report that all could endorse. This effort was essential because of rapid changes in the workforce, clinical practice models, and financial reimbursement struc- tures, which necessitate a unified effort and a constructive framework. In addition, the multi-faceted aspects of women’s health care have placed ACOG in a unique position to lead and move such an initiative forward.
Who is the target audience?
This report will be most useful for those who are charged with developing new practice models based on the changing demographics of health care practices and financial reimbursement structures. However, because of the broad and comprehensive nature of this document, its potential extends far beyond ACOG, affecting professional organi- zations, health care providers, lawmakers, advocates, and state and federal governments. All may find the guiding principles helpful in the context of their current practice and are urged to implement changes where most appro- priate. As medical teams continue to change and develop, especially in a time of predicted physician shortages and continued maldistribution, it is critical that all specialties and disciplines have a common understanding for developing team-based care to ensure that access, quality, and safety are not compromised.
The Approach
About the Task Force
As part of his presidential initiative in summer 2014, John C. Jennings, MD (then President of ACOG), convened the interprofessional Task Force on Collaborative Practice to revise ACOG’s 1995 Guidelines for Implementing Collaborative Practice publication. The task force was charged with updating and broadening the original publication, exploring team-based practice among all specialties (not just women’s health care) as a model of health care delivery that encourages a patient- and family-centered approach, responds to emerging demands, and reduces undue burdens on health care providers. In doing so, the task force was asked to first consider efficiency, quality, and value in implementation of team-based care models rather than giving primary consideration to either current or proposed payment reimbursement methods.
The task force included representatives from ACOG, American Academy of Pediatrics, American College of Physicians, American Academy of Physician Assistants, American Association of Nurse Practitioners, American College of Clinical Pharmacy, American College of Nurse– Midwives, Institute for Patient- and Family-Centered Care, National Association of Nurse Practitioners in Women’s Health, and National Partnership for Women and Families.
Methodology
The MEDLINE database, the Cochrane Library, and ACOG’s own internal resources and documents were used to conduct a literature search and to locate relevant articles. The search was restricted to articles published in the English language. Priority was given to articles that reported the results of orig- inal research, although review articles and commentaries also were consulted. Guidance published by organizations or institutions were reviewed, and additional studies were located by reviewing references of identified articles. When reliable research was not available, expert opinions were used.
Studies were reviewed and evaluated for quality accord- ing to the method outlined by the U.S. Preventive Services Task Force:
I Evidence obtained from at least one properly designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled trials without randomization.
II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncon- trolled experiments also could be regarded as this type of evidence.
III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Following review of these publications, the task force developed guiding principles, which would form the basis for the document, based on current evidence and expert consensus. The task force acknowledges that some areas of the document are based largely on expert consensus because substantial published data are unavailable. In these areas, the task force calls for this document to serve as an impetus for developing additional data on team-based care and clinical outcomes.
Endorsements
Endorsement from the following organizations has resulted in a highly peer-reviewed and widely accepted document:
 American Academy of Pediatrics (AAP)
 American Academy of Physician Assistants (AAPA)
 American Association of Nurse Practitioners
(AANP)
 American College Health Association
 American College of Clinical Pharmacy (ACCP)
 American College of Nurse–Midwives (ACNM)
 American College of Osteopathic Obstetricians & Gynecologists (ACOOG)
 American College of Physicians (ACP)
 American Society of Addiction Medicine
 Association of Physician Assistants in Obstetrics
and Gynecology (APAOG)
 Association of Women’s Health, Obstetric and
Neonatal Nurses (AWHONN)
 Gerontological Advanced Practice Nurses
Association (GAPNA)
 Institute for Healthcare Improvement
 InstituteforPatient-andFamily-CenteredCare(IPFCC)  National Association of Nurse Practitioners in
Women’s Health (NPWH)
 National Association of Pediatric Nurse
Practitioners (NAPNAP)
 National Organization of Nurse Practitioner
Faculties (NONPF)
 Pacific Business Group on Health
 Society for Physician Assistants in Pediatrics (SPAP)
The following organizations have reviewed and supported this report:
 Academy of Nutrition and Dietetics
 American Osteopathic Academy of Addiction
Medicine
Definitions
Team-Based Care
Team-based care is the provision of health services to individuals, families, and/or their communities by at least two health care providers who work collaboratively with patients and their families—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care. A team- based model of care is one that strives to meet patient needs and preferences by actively engaging patients as full participants in their care while encouraging all health care providers to function to the full extent of their education, certification, and experience.
In order to manage large amounts of information and multiple handoffs, seamless communication and transitions among health care providers (within a team or among teams) are required to support wellness and to care for patients with complex health conditions. These transitions require a shift to interprofessional collaboration that entail a necessary evolu- tion away from single-provider care to a team-based approach, which ensures patient centeredness, quality, and efficiency.
Collaborative Practice
Collaboration is a process involving mutually beneficial active participation between autonomous individuals whose relationships are governed by negotiated shared norms and visions. Collaboration is necessary for a team to function optimally, but team-based care requires more than collaboration. Each member of the team has know- ledge and skills that contribute to the work, service, and problem-solving that are the purpose of the team. Together, team-based care and collaboration foster meaningful engagement of patients and families in decision making about patients’ care.
The learned experience of collaboration and teamwork ideally begins with education programs embedded in the training curriculum of health care providers. However, establishing interprofessional collaboration within a team also requires experiential learning, building respectful relationships, and time.
The Team
The care team for a given patient is composed of health care providers (any licensed member of the team who provides clinical care to the patient) with the training and skills needed to provide high-quality, coordinated care specific to the patient’s clinical needs and circumstances. However, the definition of a team may expand beyond the traditional concept that all team members must be in the same location. For example, a patient’s team can span multiple practices and locations, especially through the use of telehealth. What is key and essential about team-based care is the movement toward enhancing communication and connectivity within and among teams so that care becomes fluid and transparent to the patient and family.
It is also important to note that the team includes health care providers as well as nonclinical team members. Also, each team is unique and, although the patient always will remain a team member, other members of a team are fluid and may change as patient care needs change.
Does every patient need an entire team?
Yes. When implemented, team-based care provides an integrated care process over the course of not just a specific or singular experience, but across a patient’s lifespan and within a regionalized care system. Ensuring coordinated and enhanced communication and connectivity among all health care providers who attend to the patient will reduce instances of overuse or unnecessary testing and improve the patient experience of care.
Guiding Principles
The patient and families are central to and active- ly engaged as members of the health care team.
Care always should be patient centered in that it is focused on the health needs of the patient; respects the patient’s values, preferences, and goals; is based on an enduring personal relationship; and sees the patient as a partner in managing his or her health and making health care decisions. This patient centeredness should be as valued as clinical outcomes.
This principle can be accomplished by establishing shared, clearly articulated goals for the process and outcomes of care, driven by the values and preferences of the patient. These goals should be mutually decided and agreed upon by the patient, the family (according to patient preference), and the health care team.
The team has a shared vision.
The team’s vision embraces patient expertise, perspectives, priorities, and needs and integrates those into the fundamental precepts of team-based care. Teams must see themselves as an integrated body of knowledge and skills that works together toward common goals rather than as individuals practicing in parallel. Teams should identify goals that all team members, including the patient, agree upon.
Role clarity is essential to optimal team building and team functioning.
Each team member is respected and recognized for his or her expertise. The team focus is on meeting the needs of the patient while maximizing the expertise of health care providers on the team. It is critical to mutually define the roles and responsibilities of each member, based on the goals and needs of the patient and each member’s qualifications.
All team members are accountable for their own practice and to the team.
Team members practice to the best of their abilities; consistently act in the best interests of patients, considering cost, quality, and timely delivery of care; accept only those responsibilities for care that are within their scope of practice and are appropriately based on their experience; integrate their profession-specific recommendations with other team mem- bers’ recommendations for care; and maintain education necessary for licensure and credentialing. Accountability is one of the best ways to develop trust with patients and families.
Continuous professional development among all team members is essential. In addition, team members create and agree upon circumstances for consultation or referral that reflect and support professional responsibility in decision
making. Teams should focus on decreasing or eliminating care that provides no benefit and may even be harmful; teams should provide care that has high value.
Effective communication is key to quality teams.
Team communication serves the dual purpose of providing an opportunity to relay important information about the task-related responsibilities of the team and providing evidence about the nature of the team’s interprofessional performance. It creates a culture that enables a continuous learning environment within the practice and translates to better and more-efficient care. Optimizing communication requires trust, honesty, transparency, and timeliness.
Team leadership is situational and dynamic.
The current health care environment necessitates a situational and collaborative approach to team leadership that best meets patient needs and goals. Thus, the team member who can best address the priority needs of the patient assumes the lead health care provider role. “Shared power” often is used synonymously with collaboration and team care and connotes a collective approach to optimizing care.
Changes in leadership should result from the team’s overall and unified discussion concerning the best path of care for the patient at any given point in time. Practices should encourage patients to be a part of the decision-making process regarding team role and responsibility changes and, if patients are not part of this process, they should receive complete, timely information regarding these changes.
Implementation of Team-Based Care
Team-based care, coupled with traditional and nontraditional but evidence-based implementation tools such as telehealth and virtual teams, has the potential to improve health disparities and improve health care access for more of the U.S. population.
It is essential to first assess the needs of the population being served. The composition of a care team will then depend on the local population and population health. Health disparities exist across the country and are common among patients who live in regions with poor access to primary and specialty health care.
Team-based care has the potential to expand the venues at which health care is delivered. In addition to the tradi- tional settings of care, a variety of additional options for health care delivery should be considered when implementing a team-based practice. Such settings include, but are not limited to, colleges, churches, homeless shelters, public housing projects, public schools, mobile health units, birth centers, adult day centers, nursing homes, patients’ homes, continuing care retirement communities, retail clinics, prisons, and juvenile detention facilities.
Finally, telehealth has broad and growing applications in health care delivery and also should be considered for delivering team-based care, especially when access is limited. However, fully incorporating telehealth more broadly into practice requires additional emphasis and clarity in the curriculum for all health care providers. Professional health care curricula should support wide use of and instruction in best practices associated with telehealth, particularly to support rural and underserved settings.
Statutory and Regulatory Considerations for Team-Based Practice
Practices and health care providers should be aware of their state requirements and obtain appropriate legal advice when considering entering into legal agreements designed to sup- port team-based care, such as employment, consultation, or supervisory agreements. In addition, although the integrated team-based approach represented in this document is one in which health care providers should be able to practice to the full extent of their education, certification, and experience, practices should recognize that scope of practice and licen- sure are ultimately established by laws and requirements in each state. Health care providers and practices seeking to build interprofessional health care teams should understand the scope of practice and licensure of each member of the health care team. Health care providers and practices also should understand how such scope of practice is determined, including state law and regulatory requirements, so that all health care providers within the team can function at the highest level of education, certification, and experience with- in the confines of their state’s regulatory scheme.
Although authority for scope of practice determination and regulation resides with individual states, professional health care associations have established and should continue to establish clinical practice guidance and should promote uniform educational requirements, standards of care, and standards of conduct for their specific professions. States should rely on clin- ical guidance set by professional associations when licensing and regulating health care providers. This would help bring uni- formity to licensure rules and practice norms across all states.
Opportunities for Implementation
Key challenges exist in the implementation of team-based care as a result of the current regulatory environment. Some cannot be resolved immediately or solely by the team or practice itself; however, each challenge represents an opportunity. Most im- portant though, is the willingness to work toward achieving the guiding principles (as outlined in Chapter 2). Opportunities for change center around cost and payment; practice functionality, workflow, and communication; and partnering with patients.
Cost and Payment Tied to Quality
Support for team-based care should focus on reimbursement for improved outcomes, while patients, payers, hospitals, and practices are held accountable for costs. Payers should create incentives for high-value care that improves outcomes while decreasing costs. In addition, this care should be supported by evidence-based guidance and best practice, and delivered in a team-based care model. However, payers also should recognize that there will be instances when high-value care will not decrease cost or when the cost savings is not seen in the short-term.
Payment systems should evolve so that all members of the team can benefit from financial incentives based on outcomes and value of care instead of exclusively by procedure or volume of procedures; outcomes measured may include patient adherence, patient experience, maintaining preventive services at high rates [Healthcare Effectiveness Data and Information Set (HEDIS) metrics], and minimizing hospital admission and readmission.
Practice Functionality, Workflow, and Communication
As health care providers are increasingly encouraged to function to the full capability of their education, certification, and expe- rience, practices may initially struggle with how to best allocate responsibility to various members of the team. Navigating the interconnectivity of scope, complexity, cost, revenue, and health care provider availability can be difficult, and individual health care provider attitude can exacerbate the challenge. Professional respect and willingness to understand skills of all members of the team are foundational to fostering effective workflow.
Partnering With Patients
Perhaps the most underappreciated challenge facing prac- tices seeking to establish a collaborative approach to care is that of designing clinical, operational, and administrative services that are built on a firm commitment to build partnerships with patients. This includes engaging the patient in shared decision making so that health care decisions are based on best evidence as well as a patient’s values, goals, and preferences. These challenges can be overcome through a number of strategies, including the following: educating team members on the beneficial effects of partnering with the patient and family; using reliable, high-quality decision aids and other decision support tools and patient engagement techniques that help health care providers pre- sent evidence-based information on all care options; ensuring clarity of the lead health care provider, the role of each team member, and providing appropriate contact information to assist in management of the patient’s condition; and facilitating the patient’s participation in shaping his or her clinical goals and outcomes.

Conclusion
Optimally implemented, the team-based approach provides integrated care over the course of a specific experience, as well as across a patient’s lifespan and within a regionalized care system. Some aspects of creating a team-based approach may be difficult to implement or transition to at first, but long-term benefits (such as achieving the Triple Aim) are expected to outweigh short-term difficulties. Many practices already may be informally functioning in a team-based care model, so the transition may be fairly straightforward. For some practices, the transition will be more about building upon and codifying informal approaches or policies that already exist. Others may require analysis and redistribution of responsibilities to safely increase efficiency. In addition, there may be some practices that will identify more opportunity to build in patient and family feedback. The guiding principles are intended to provide practices and organizations with a practical blueprint of how to successfully transition to a team-based approach.