Team-Based Care in the Pediatric Office

​​​​​​​​Team-Based Care in the Primar​​y Pediatric Practice – Implementation Strategies

Determine Team Composition
Team members provide integrated, comprehensive care for patients and their families in the primary pediatric ambulatory care setting.  
The team should be led by the pediatrician and can include pediatric nurse practitioners, physician assistants, nurses, telephone triage nurses, medical assistants, administrative staff (eg, front office, billing, information technology, scribes), mental health professionals, social workers, dietitian/nutritionists, care coordinators, youth/families and/or others. 
Team composition may vary depending on the needs of the patient population. Children and adolescents with certain acute problems or chronic conditions may require inclusion of pediatric medical and surgical specialists and subspecialists as remote members of the team. 
For instance, medical assistants, schedulers, front office, billing staff and information technology staff may be responsible for referral tracking, fulfilling tasks on the plan of care, appointment recall, and other tasks. Nurses may perform the responsibilities of care coordination such as seeing that medical diagnostic results are received, specialist appointments are kept, and home care is coordinated.     
Every practice is different. What works in one pediatric practice may not work in another. The model of team-based care should be specific to each practice’s patient needs, community resources, and the individuals on the team. The key is to be dynamic, changing, and evolving when new patient needs arise, community resources change, and team composition requires adaptation. ​​ 
Reso​​​​urce: Worksheet​ on thinking about the practice's team-based care  
Select a Leader
​Optimal pediatric health care depends on a team-based approach with supervision by a pediatrician leader, per the AAP policy statement on scope of practice. A pediatrician is uniquely qualified to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all ambulatory primary care practice settings.
A pediatrician who leads a health care team also determines when referral to other physicians is warranted. Under the pediatrician leader's guidance, a full range of health care services may be managed by other team members—all facilitating comprehensive, coordinated, patient centered care. ​ 
Develop Team Mission Statement
Create a mission statement for the practice that speaks to its aims for team-based care. Characteristics of effective mission statements are as follows: value, inspiration, plausibility and specificity. 
Involve staff in the development of the mission statement as equal participants on the team. Consider involving youth and families in this process. 
Describe the value of team-based care in a way that encourages employees as well as the patients/families in the practice, sounds reasonable and plausible, and is specific and relevant. Use concise sentences.   
Distribute drafts of the mission statement to every employee (and youth/families if applicable), and ask them what, if anything, should be added or changed. Not only will this result in a better, more comprehensive statement, but employees and the patients/families in the practice will be more invested in it because they helped form it. It should be stated clearly so that it is understood by all. 
Convey the mission statement to others inside and outside the practice. Post it in the office, where practice leaders, employees, patients and their families, and visitors can see it every day.  Place it on practice materials, such as patient brochures, employee training manuals, letterhead and the practice website.​ 
For more information: 
• Practice-friendly curriculum on objectives for team-based care  
• Handouts, slides, brief videos 
  • ​Implementing Care Teams 
  • Healthy Huddles 
  • Optimize the Care Team​​​ 
Define Clinician and Non-Clinician Team Members Roles
Outline all responsibilities and tasks that need to be performed to provide high quality, accessible, family centered, continuous, coordinated and comprehensive care to patients and their families 
Develop a comprehensive list and obtain review from other members of the practice team to determine whether anything is missing. 
Determine what tools and resources are needed to carry out each task 
For instance, an office clerk administrative team member may be designated to collect data on a daily or weekly basis, and a practice manager may collate and identify gaps in quality control and assurance. Potential resources might include "protected" time to carry out the expected transformation duties, or templates to automate processes within practice management software and/or electronic health records. 
Match team roles to scope of practice, licensure, training and capabilities fostering team care 
List the responsibilities and tasks that need to be performed and which staff should be assigned to each role. Clearly define roles for each staff member based on skills, capabilities, and within scope of practice and licensure established in state laws. (This information can be found within each professions' state licensing authority.) Consideration of staff costs and overhead for a practice is essential in this process. Use this information to craft job descriptions for each team member. 
Create training manual with step-by-step guidance on each task 
In addition to the job descriptions for each team member, create a training manual for members of the team. It should include step-by-step procedures for each task required to fulfill the responsibilities as noted by their job description. Once staff roles and responsibilities are defined, review this information with staff to obtain input and to identify specific areas where additional training is needed. Revise job descriptions as needed. 
Distribute training manual, including job description roles and responsibilities, among care team members 
Provide staff with their newly defined job roles and responsibilities once they have been documented in the training manual. These are essential elements for the practice's policy and procedural manual and should be used for orientation, training, and team evaluation. 
Cross-train care team members 
Train a staff member thoroughly on job duties and responsibilities. Then, when skills and knowledge base are at a satisfactory level, have that staff member mentor another employee in the role. 
Evaluate team member performance 
Customize team member performance evaluation tools to include the new responsibilities. Provide fact-based feedback assessing team members' performance compared to job descriptions and tasks. QI reports, patient survey results, team member peer review, team leader evaluations, and self-assessments are documented sources of performance and should be referenced. Provide additional training to address any problem areas.  
Adapt Workspace to Facilitate Team-Based Care
Care teams can be more successful if their workspace is designed to support direct communication and collaboration and ease a patient's journey through the clinic. 
Workspace design should: 
• Promote coordination and communication among team members 
• Be patient-friendly, reduce patient anxiety by being conducive to privacy, comfort and a clear understanding of the care plan 
• Accommodate day-to-day variations and be flexible enough to accommodate new models for primary care delivery 
• Reduce waste and cost 
• Employ standardization in design and equipment and place needed equipment in exam rooms to promote patient safety and decrease error 
• Integrate necessary technology 
Ways that traditional office space does not facilitate team-based care: 
• When physicians and staff often work in various parts of a medical office communication can be hindered because they do not have a consistent line of sight to their fellow team members 
• Storing necessary supplies and equipment in special rooms separate from the exam room, requires staff to leave the care area to acquire what they need, which is inefficient 
• Variation among exam rooms in layout and location of supplies causes wasted time as team members must orient themselves to each room 
• Electronic health records (EHRs), computers, and monitors are set up in exam rooms so that a physician's back is to the patient and family, which hinders communication and make interactions less effective 
• Clinical staff work areas are often not located near exam rooms 
• Patient flow paths are often illogical and can confuse patients. Patients move through work areas where protected health information is stored and conversations regarding patient care are occurring. A clear space for "check out" at the completion of a visit is often missing, resulting in patients leaving the office without follow-up appointments, referrals and post-visit instructions. 
If possible, redesign office space to optimize patient flow and to co-locate team members in work zones for pre- and post-visit work in order to facilitate communication and collaboration. Ideally this space would also be situated so that team members will not be easily observed or overheard by patients and families. 
For more information: Healthcare​ Design Magazine article on workspace for team-based care 
Pre-Visit Preparation
Prepare for upcoming patient visits by reviewing a patient's record (particularly issues occurring since the last visit) and identifying issues that should be addressed either before or during the patient visit. Communication between team members may be electronic messages, e-mails, or notes in a patient record. The following steps are options to help implement communication between team members when preparing for patient visits: 
Create an internal communications team 
Choose a lead clinician, referral-tracking staff member, clinical nurse and scheduler to join as a team to develop a process for internal communication among all team members. The lead clinician may be a physician, mid-level practitioner, nurse, or practice manager. This team will lead the practice in implementing team-based care communications. 
Create policies and procedures for internal communication 
Document a policy and procedure for structured preparation of upcoming patient visits. This should include identifying critical patient needs to be addressed either before or during the visit. In the policy, demonstrate how communication occurs regularly by including samples of meeting minutes, agendas, or memos/e-mails to staff. Team meetings should be held weekly (at a minimum), to discuss scheduled patients and identify whether any pre-visit information or resources will be needed to maximize efficiency during the office visit. For example, the team may need to contact a patient, obtain lab reports, review prior records, review screening reports, or obtain and review diagnostic studies. 
Team huddles 
Short team meetings or "team huddles" should be conducted once or twice a day; ideally prior to the start of the morning session and afternoon session in the practice. When bringing the team together, select a place that is convenient and suitable for open discussion of patient information.   
The purpose of the team huddle is to review the patient schedule for the next segment of the day and prepare for potential challenges, such as patients with complex health needs who require additional time or staff support. In general, team huddles should be brief (ie, less than 10 minutes in duration), and focused on planning tasks related to the next set of patients. In general, the team should discuss patients with complex conditions, patients who have been recently seen in the Emergency Department or hospitalized, patients who are often late or have high service needs, patients who are missing recommended preventive care services, or patients who will require additional time or attention from staff. 
The team huddle could also be used to briefly review the previous day, and to discuss hospitalized patients or other patients who require specific follow-up. The team should decide who will provide any necessary follow-up and the timeframe the follow-up should take place. Team huddles should be led and monitored by the lead clinician for frequency and compliance among staff members.  
To ensure successful team meetings and huddles, practices should: 
1. Activate the answering service during team meetings and huddles to assist with calls 
2. Block off an appropriate amount of time so that patients are not arriving during meetings/huddles if all staff will be involved 
3. Have an agenda and record minutes or action items 
4. Address all staff questions, concerns and suggestions  
Types and Frequency 
• Daily Team Huddles – Team huddles are meetings, typically held at the beginning of each day, that are brief in duration (15-30 minutes in length). Non-clinical and clinical team members come together to discuss the updates and priorities of the day, as well as the day's appointment schedule. During this time, any anticipated patient care needs or care coordination needs are discussed. Attendees required should include but are not limited to: Providers, NPs, RNs, LPNs, MAs, Care Coordinators, and Front Desk staff.  
• Clerical Staff Meetings – It is recommended that clerical staff meet on a bi-weekly basis for at least 30 minutes. This time can be used to discuss schedule template updates, provider updates or vacation schedules, and other issues that need to be brought forward to practice leadership. 
• Clinical Staff Meetings – Clinical staff should meet approximately every three months to review patient protocols and clinical issues. For example, once a month (grand rounds day), a physician could teach other clinical staff about a specific topic (eg new Periodicity Schedule recommendations). 
• All-Staff Meetings – These meetings should be held on a quarterly or bi-annual basis with mandatory attendance. Meetings should cover updates to topics such as new practice policies, regulation changes that impact all staff (eg. HIPAA or OSHA), in-services on quality improvement topics, and preparation for flu shot clinics, back to school, and sports physicals. 
Resources: 
• Video: How to Efficiently Create Team Huddles (8:29 minutes) - National Center for Medical Home Implementation (August 2013) 
• National Center for Medical Home Online Resource Guide: Building Your Medical Home - Team-based care Team Huddle videos 
​Post-visit communication with patients 
Have systems in place to identify patients telephoning with concerns that problems treated within the past 48 hours have persisted or worsened. Identify return visits and Emergency Department visits for the recently treated problem. Establish policies to verify that this information is shared with clinicians and addressed rapidly. 
Collaborate with the Patient and Family
Post-visit medical summaries are developed together by the practice's care team and the patient and/or family to address the patient's health needs and goals. Once goals have been established, they should be reviewed and modified, as necessary, at each relevant visit. 
​Provide each patient with a post-visit medical summary during the relevant visit 
The practice will provide a written or electronic summary developed in partnership with the patient and family.    
​Assess and address barriers when the patient does not meet goals 
A physician or care team assesses or talks with the patient or family to determine reasons for limited progress towards goals, and to help the patient and their family address barriers. Some examples of barriers may include patient's lack for understanding, insurance or monetary issues, or medication side effects. Based on these conversations, the physician or care team may need to discuss modification of goals with the patient and/or family and come to a mutually agreeable plan that patients and families believe they can follow.​ 
Identify patients and families who might benefit from additional care management support 
Assess, and when appropriate, refer patients to clinical specialists or community resources for additional care management support, such as disease management or case management programs. 
Establish a Clear, Realistic and Specific Follow-up Process for Patients
​Establish and implement a policy and procedure to follow up and recall patients who have not kept appointments for preventive care, chronic disease management, re-evaluations for acute illness, and post-hospital admission/discharge follow-up.​ 
Assess and Evaluate the Care Team for Opportunities to Improve Care Team Processes
Measure and evaluate the quality of the practice's medical records against the practice's medical record review sheet 
Monitor communication among team members as documented in the medical record. Evaluate random samples of patient charts over a one-month period to verify that documentation of communication in the medical record is accurate, complete, clear, and concise. This may be done by comparing individual medical records against a medical record review sheet, which identifies important elements to be documented in pediatric medical records. Review and assess the effectiveness of communication within the care team and with outside providers. 
​Resou​​rc​e:Sample Medical Record Review Sheet​ 
Measure and evaluate the practice's team-based care. 
Tools exist to measure whether a practice is working together as a high-functioning team to deliver team-based care. These tools include specific measures to understand specific areas where improvement is needed. 
​Use the Model for Improvement tools to create action plans for the areas in which improvement needs to take place as identified by a record review 
Based on the evaluation of communication between staff, develop a quality improvement process to address identified gaps and flaws in how communication is exchanged. Allow staff to work as a group to help develop action plans that will be implemented to improve communication processes in the practice. Having the entire care team involved will also help create a practice culture that values continual quality improvement. See the Quality Improvement module for additional information.  
​Share results and discuss (and document) action plans 
Once data are analyzed and team members have created action plans, hold a care team meeting to share results. The practice will want to develop minutes from these quality improvement and staff meetings to document discussions and action items. At the start of each meeting, review the minutes of the prior meeting. This allows staff to be updated, recognize prior efforts, and establish a starting point for the meeting's discussion. 
Update communication policies and procedures to address identified quality improvement actions. Provide additional staff training on changes in policies and procedures resulting from QI 
Team meetings should include suggestions for change or improvements in communication process. Implement the action plans that have been created to improve patient care coordination, provide tailored services to practice-specific population, and improve patient satisfaction. 
Resou​rces:​​ 
• National Center for Medical Home Implementation Online Resource Guide: Building Your Medical Home 
• AAP Scope of Practice Issues in the Delivery of Pediatric Health Care - Policy Statement​