Team-based Service Coordination in Practice: Working with Care Managers
What is commonly called “team-based care” is well established to improve stability and outcomes for individuals with medical complexity, especially including patients with intellectual and developmental disabilities (IDD). The American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetrics and Gynecology have all reviewed the evidence and endorsed “team-based care” as an optimal model for such special needs populations.
However, what does “team” mean? The nature of the team structure, the roles and responsibilities of team members, and the relationship among team members who may not all have the same organizational affiliation are always challenging when trying to coordinate care for an individual with multiple, diverse disciplinary needs.
Individuals with IDD often have complex “health resource communities,” meaning those individuals, organizations, entities, and environments (including the patient and their family) that have any involvement or influence—actual, virtual, or potential—on the variables that influence their health and well-being.
In our current systems of practice, the responsibility for the elements of any patient’s care is often apportioned independently among different professional disciplines (primary care and specialist physicians, nurses, therapists, social workers, etc.) who, based on the mental model of their discipline, contributes insights and any related orders or action items.
Unfortunately, when decisions are made in isolation of other members of the patient’s health resource community, it can lead to fragmented and uncoordinated care, adding risk to the patient and family, especially those with IDD.
Even under an interdisciplinary model, teamwork is really “groupwork”: while all necessary domains may be represented, members actually work in parallel on tasks that match their purview; achievement of individual goals among the team members is expected to add up to the groups purpose.
However, interdisciplinary is not the same as integrated. And the diverse, often complex needs of the IDD community can often stress the capacity of individual providers. As noted in the 2018 National Academy of Medicine discussion paper “Optimal Team-Based Care to Reduce Clinician Burnout,” well-defined team-based care presents a unique opportunity to improve patient outcomes, the efficiency of care, and the satisfaction and well-being of health care clinicians.
High performance goal achievement in environments characterized by complexity and diverse human factors requires sharing responsibility, authority, and accountability among team members. To be successful, this model of collaboration must be based on a belief that the benefits of collaboration will offset perceived costs such as loss of autonomy and territorial control. Then, care delivery becomes a collective enterprise as opposed to a departmental, command and control phenomenon, with active coordination of goals and activities to effectively resolve complex problems that could have dire consequences in the face of failure.
In the symphony, performers use their instruments in collective effort to create a harmonious and moving experience for the audience. Extraordinary collective performance—whether in technology, special forces, or healthcare—is also symphonic: dozens of technical and interpretive experts, each of whom has invested in mastering their specific instrument or craft, come together, subsume their individual identities, and, in a shared effort, are able to create a concordant, goal-directed experience.
The conductor is not the leader, but serves an essential integrating role, holding the vision for the performance as a whole. Even the most virtuoso players understand they cannot conduct and sit first chair; they respect, trust, and defer to the conductor and listen carefully—not for reaction, but for connection—to their fellow players, because they understand that a solo may be in their hands, but the symphony only exists in the collective effort.
In our current systems of care, a well-trained and comprehensive Care Manager is the ideal “conductor,” serving an essential integrating role, holding the vision for “whole-person” outcomes. Their expertise is orchestrating collaboration and a single focus on facilitating the goal-directed activities of team members.
However, it’s important to understand that there are many different forms of care management. Knowing the specifics of an organization’s care management model will help you make better decisions as to who is on your team for specific patients. For medically complex patients, such as those with IDD, Care Managers should be open to augmenting your staff and engaging in activities that promote access to care. They will also help patients and families navigate the healthcare system, identify, and engage referrals, coordinate and support the management of transitions of care (home/residence to hospital, hospital to skilled nursing facility or SNF, SNF to home/residence), follow-up on emergent or urgent care needs and provide linkages to social and government services, community supports and long-term care, and hold interdisciplinary team meetings. They can also conduct or refer for specialized functional and risk assessments, which can add to the data used in your practice for decision making and quality improvement. That data will be useful to create integrated patient-centered plans of care based on IDD best practices to ensure appropriate access to resources and services, including preventive interventions, safety plans, and necessary equipment.
For example, New York State (NYS) has developed a care management model for the IDD community that is used in the IDD-focused Care Coordination Organizations/Heath Homes (CCO/HHs). The CCO/HH model offers a unique, well-defined and predictable level of service that can offer great value to healthcare services organizations. Care Managers at CCO/HHs and CCO-associated health plans have extensive experience working with individuals with IDD; some are Qualified Intellectual Disabilities Professionals (QIDP). As the primary relationship managers for patients and families eligible for services under NYS Office of People With Developmental Disabilities (OPWDD), Care Managers can serve an “essential integrating function” in your practice. While most health plans offer their own form of care management, some health plans choose to partner with CCO/Health Homes for IDD patients because of their model of care and disciplined performance.
Collaboration in Practice: Implementing Team-Based Care. Pediatrics. 2016 Aug;138(2):e20161486. Available from: doi: 10.1542/peds.2016-1486. PMID: 27456515.
Doherty R, Crowley, R. Health and Public Policy Committee of the American College of Physicians. Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper. Ann Intern Med. 2013 Nov 5;159(9):620-6. PMID: 24042251.
Mitchell P, Wynia M, Golden R, McNellis B, Okun S, Webb E, Rohrbach V, Von Kohorn I. Core Principles & Values of Effective Team-Based Health Care. NAM Perspectives. Discussion Paper, National Academy of Medicine, 2013.Available from: https://doi.org/10.31478/201210c.
New York State Department of Health, New York State Office for People With Developmental Disabilities [Internet]. Care Coordination Organization/Health Home (CCO/HH) Provider Policy Guidance and Manual. 2018 Aug; Ver 2018-1. Available from:https://opwdd.ny.gov/system/files/documents/2020/01/cco-policy-manual-master_acc_1.pdf.
Smith, C, Balatbat C, Corbridge S, Dopp A, Fried J, Harter R, Landefeld S, Martin C, Opelka F, Sandy L, Sato L, Sinsky C. Implementing Optimal Team-Based Care to Reduce Clinician Burnout. NAM Perspectives. Discussion Paper, National Academy of Medicine. 2018. Available from: https://doi.org/10.31478/201809c.