Team-Based Healthcare for Chronic Disease Management

Overview: Team-Based Healthcare

In the US, it is clear that the current healthcare infrastructure is inadequate to meet the population's current and future needs. Several critical factors contribute to this issue. First, the absence of universal healthcare leaves many Americans struggling with affordability, creating significant barriers to accessing care. Meanwhile, despite spending significantly more on healthcare than other high-income countries, healthcare outcomes are comparatively much worse than peers. Lastly, the U.S. faces a high prevalence of chronic conditions, with the highest rate of people living with multiple chronic illnesses among high-income countries and an obesity rate nearly twice the OECD average.

The improved prevention and management of chronic conditions in particular is critical to developing the capacity to offer comprehensive, continuous, well-coordinated care. As the burden of conditions such as diabetes, heart disease, and obesity continue to grow, traditional models of care—often centered on the physician-patient relationship—are proving inadequate. 

To effectively address the complexities of chronic diseases, we must embrace team-based healthcare delivery, defined by the National Academy of Medicine as “the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers to the extent preferred by each patient to accomplish shared goals within and across settings to achieve coordinated, high-quality care”. This model integrates the expertise of various healthcare professionals to provide comprehensive and patient-centered care.

Team Composition

A key aspect of effective team-based care lies in the collaboration of team members. The team, including the patient, and in some cases family or carers, need to work together to establish shared goals, which align with the best interests of the patient. To enable this, teams need to decide on clear roles, ensure no overlap of responsibilities, establish effective communication methods and agree on how to measure outcomes. Fundamentally, it's essential that each team member values the unique contributions of others, without considering any role as superior.  Team members can include the following: 

• Pharmacists: The Medication Experts in Chronic Disease Management

Pharmacists are uniquely positioned to play a critical role in chronic disease management, particularly in optimizing medication use. Research has shown that pharmacist-led interventions can improve medication adherence and reduce adverse drug events, both of which are key to managing chronic diseases effectively. Through collaborative drug therapy management agreements (CDTM), patients can receive access to cutting-edge treatments and clinical trials, oftentimes out of reach in common clinical practice.

By working closely with physicians and other members of the healthcare team, pharmacists can ensure that patients are on the most appropriate medications, understand how to take them correctly, and are aware of potential side effects. This collaborative approach not only improves patient outcomes but also reduces the overall cost of care by preventing complications and hospitalizations.

• Health Coaches and Navigators: Bridging the Gap Between Patients and Providers

Health coaches and navigators are becoming increasingly important in chronic disease management, serving as vital links between patients and the healthcare system. Health coaches work with patients to set and achieve health goals, providing the education and motivation needed to make lasting lifestyle changes. A study in The American Journal of Medicine found that patients with chronic diseases who worked with health coaches had improved self-management skills and better clinical outcomes, including lower blood pressure and improved lipid profiles.

Navigators, on the other hand, help patients navigate the often-complicated healthcare system, ensuring they have access to the services and resources they need. This role is particularly important for patients with multiple chronic conditions, who may require care from several different specialists. By coordinating care and advocating for the patient, navigators can help reduce the fragmentation of care that is all too common in chronic disease management.

• Advanced Practice Providers: The case for nurse practitioners and physician assistants to act as the first clinical contact

While physicians are integral to high-quality care teams, structuring highly trained, experienced, and specialized doctors to act as the primary contact and necessary input for each node of a patient journey is inefficient. By ensuring that patients are triaged to appropriate clinical resources through defined care pathways, we can streamline access issues and improve both the patient and provider experience. 

Challenges for Implementation

While team-based care has the potential to improve patient care, the implementation of the model is not without challenges. For healthcare staff, these include insufficient staff resources, and inadequate staff training, as well as the perception that the team-based model may affect the nature of healthcare work and disrupt existing relationships. Furthermore, team-based care requires the patient to take a significant role in guiding their care, which not all patients will be comfortable with and will require healthcare leaders to adopt a more adaptable approach for individual patients. 

Moreover, reimbursement practices don’t necessarily align with the model of team-based care. Many reimbursement policies reward individual encounters, as well as prioritizing physician services, offering limited payments for care provided by other team members.  Meanwhile, variable federal and state regulations can limit the scope of care for non-physician providers, limiting the role they can play in team-based care. While licensing laws can create obstacles to forming comprehensive teams, especially across state lines. 

Team-based Care: A Collaborative Future for Chronic Disease Care

The shift towards team-based healthcare delivery for chronic disease management represents a fundamental change in how we approach patient care. By leveraging the strengths of remote care, pharmacists, health coaches, and navigators, we can create a more coordinated, patient-centered, and effective healthcare system.

The evidence is clear: team-based approaches not only improve clinical outcomes but also enhance patient satisfaction and reduce healthcare costs. As we continue to face the challenges of an aging population and a growing burden of chronic disease, embracing this model of care is not just an option—it is an imperative.