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Continuous & Team-Based Healing Relationships


Implementing care teams is a critical element of transforming a practice into a patient-centered medical home. A care team is a small group of clinical and non-clinical staff who, together with a provider, are responsible for the health and well-being of a panel of patients. Who is on the care team and their specific roles will vary based on patient needs and practice organization.

Key changes for Continuous and Team-Based Healing Relationships:

  • Establish and provide organizational support for care delivery teams accountable for the patient population/panel.
  • Link patients to a provider and care team so both patients and provider/care team recognize each other as partners in care.
  • Ensure that patients are able to see their provider or care team whenever possible.
  • Define roles and distribute tasks among care team members to reflect the skills, abilities and credentials of team members.
  • See examples of one SNMHI participant's interventions and results for this Change Concept.


Continuous and Team-Based Healing Relationships Resources

Implementation Guides

Continuous and Team-Based Healing Relationships Executive Summary

Continuous and Team-Based Healing Relationships: Improving Patient Care Through Teams
This Implementation Guide provides guidance on how practices can develop and sustain strong care teams.

Continuous and Team-Based Healing Relationships Supplement: Elevating the Role of the Medical/Clinical Assistant
This supplement provides a curriculum and training materials (PowerPoint presentations, handouts, skill assessments, exams, etc.) that practices can use to enhance the skills of MAs/CAs. In the heading of each section is a Zipped File Icon. Click this icon to download a zipped file containing all the resources for that section

Tools

Team-Based Planning Worksheet
Types of Call Study
Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit

Webinars

Deeper Dive on Team Roles Part 2 (October 25, 2012)
Moderator: Nicole Van Borkulo, MEd, Qualis Health
Speakers: Catherine Dower, JD; Susan Chapman, PhD, RN; and Lisel Blash, MS, MPA, UCSF Center for the Health Professions (San Francisco, CA); Christine Klucznik, Cambridge Health Alliance (Boston, MA) ; Ann Turner and Sarah Deines, Virginia Garcia Memorial Health Center (Cornelius, OR)
Audio & video program
Presentation slides

Deeper Dive on Team Roles Part 1 (October 3, 2012)
Moderator: Diane Altman Dautoff, MSW, Qualis Health
Speakers: Ed Wagner, MD, MPH, MacColl Institute for Healthcare Innovation at Group Health (Seattle, WA)
Lara Salazar, SPHR, Montana Primary Care Association (Helena, MT)
Sue Barba; Ashley Crawford, LPN; Megan Kiser, RN; Jessica Carmen; and Susan Hamilton, Beaver Falls Primary Care & Behavioral Health Center (Beaver Falls, PA)
Jay Brooke, High Plains Community Health Center (Lamar, CO)
Audio & video program
Presentation slides

Optimizing the Role of the Front Desk Staff (December 15, 2011)
Moderator: Katie Coleman, MSPH, MacColl Center for Health Care Innovation at the Group Health Research Institute (Seattle, WA)
Speakers: Katie Bell and Prathiba Pinnamaneni, Neighborcare (Seattle, WA)
Audio & video program
Presentation slides
Neighborcare Medical Clinic Tasking Guidelines

Optimizing Your Care Team in the Medical Home (April 30, 2010)
Moderator: Donna Daniel, PhD, Qualis Health
Speaker: Catherine Tantau, BSN, MPA, Tantau & Associates
Audio & video program
Presentation slides

How to Deploy Teams that Provide Continuous Team-Based Care (January 12, 2010)
Moderator: Ed Wagner, MD, MPH, MacColl Center for Health Care Innovation at the Group Health Research Institute (Seattle, WA)
Speakers: Pat Jacobsen, RN, and Morris Askenazi, MD, La Casa/Quigg Newton Family Health Center (Denver, CO); Somava Stout, MD, Kirsten Meisinger, MD, Megan Littlefield, MD and Nitzali Rivera, MA, Cambridge Health Alliance (Boston, MA)
Audio & video program
Presentation slides
Mammogram Workflow Sheet

Structured Communication Methods to Enhance Team-Based Care (November 23, 2009)
Speaker: Sharon Eloranta, MD, Qualis Health
Audio & video program
Presentation slides

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Kathryn Phillips, MPH
Director, Safety Net Medical Home Initiative
(206) 288-2462
(800) 949-7536 ext. 2462
kathrynp@qualishealth.org