Teaming Up with Patients,
Families, and Community to
Improve Health Care
Perry Dickinson, MD
Department of Family Medicine
University of Colorado Denver
Outline
• Transdisciplinary teamwork in the practice
– clinicians and staff members
• Patient- and family-centered care
• Community focus
• What do we know about teams?
Which Way Are We Headed?
Possibilities...
• The PCMH model, if fully realized, will
encourage and incent clinicians and practices
to team up with patients, families, and the
community to improve health
• Coordination of care, population management,
patient centered care all focus people in that
direction
• Dependent on payment, other structural
issues – but also very dependent on us
• Requires a cultural transformation
PCMH is a Team Sport
• No way for primary care clinicians to provide
everything their patients need by themselves
• Multiple levels of teamwork necessary:
– Clinicians and staff members
– Coordination with rest of health care system
– Patients – personalized care plans, selfmanagement, patient advisory groups
– Community partners
Teams in the Practice
• Multiple studies - using staff at higher level in
team approach increases patient, staff,
clinician satisfaction, quality and efficiency of
care
• Goal is everyone working at the top of their
license and skills
• Physicians are usually the biggest hurdle –
hesitant to delegate tasks
• Also cultural transformation for staff, patients
Working Together
Levels of Team Care
• Multidisciplinary – each discipline
independently contributes its expertise –
work in parallel
• Interdisciplinary – team members work
together closely, communicate frequently
to optimize care – each contributes skill
and expertise to support the team’ work
• Transdisciplinary – roles blur as functions
overlap, interchange
Who Is The Team?
• Within the practice – everyone – front office, MAs,
RNs, FNPs, PAs, physicians
• Sometimes within the practice (or at least wellcoordinated with the practice) – mental and
behavioral health, care managers, social
services, pharmacists, others….
• Patients and families are important team
members at all levels
• “Medical Neighborhood” – other professionals or
organizations that “share care” for your patients
• Community resources
Population Management
• Chronic Care Model and PCMH both
increase practice’s focus on populations of
patients instead of the individuals who
present for care
• Responsibility for health (and quality
indicators) of entire population of patients
signed up for care
• Increases awareness of importance of
community issues in determining health
Core Concepts of Patient- and
Family-Centered Care
• Respect and dignity – patient and family perspectives,
cultural norms, beliefs, and choices are listened to and
honored
• Information Sharing – receive timely, complete, and
accurate information
• Participation - in care and decision-making encouraged
and supported
• Collaboration - on a practice-wide basis in design of
delivery of care
• Feedback – from patients is regularly sought and
listened to
Patient Input
• Multiple ways to obtain patient input and
feedback for practice change and improvement
• Tremendous source of wisdom, ideas
• Patient and family advisors
– Advisory councils
– Involvement in practice improvement teams
• Takes time and patience (for both patients and
practice) to develop fully
• Patient experience survey as a quality measure
Self Management Support
• Providing patients with the information, tools,
and support they need to take care of health
problems in their daily lives
• Not patient education
• Personal health plans developed with patient
prioritization, goal setting, action plan,
monitoring
• Requires that we partner with the patient and
family in a different way
Community Engagement
• Many of the resources for selfmanagement support are in the
community
• Have to identify and partner with
community groups
• Should lead to assessment of strengths
and problems in the community
• Can lead to community-level advocacy
Teamwork Is Central to the
PCMH
• So what do we know about teamwork?
Crucial Elements of Teamwork
• Mutual respect and trust
• Willingness to abandon assumptions
• Understanding of the distinct roles of each
team member…
• But, a willingness to blur roles when
appropriate
• Flexibility
• Communication
• Relationships!
Effective Teams Need
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Clear purpose - vision
Coordination, time to meet
Patience – it takes time to get there
Protocols and procedures
Conflict resolution skills (and willingness)
Active participation by everyone
Collective and individual accountability
Barriers to Teamwork
• Traditional hierarchical leadership
• Reluctance to question “the leader” or “the
expert”
• Cultural differences – “cognitive maps”
• Unwillingness to take on new roles
• Communication styles
• Lack of supportive organizational structure
• Exclusion of team members
Reality
Even if you are on the right track, you’ll get
run over if you just sit there
~ Will Rogers
Thank You!
• Contact Information:
– Perry Dickinson:
perry.dickinson@ucdenver.edu