As the US health system moves to value-based care and aligns payment with quality, the role of the primary care provider (PCP) is becoming ever more important. The purpose of this paper is to outline a successful population health and care management strategy depending on accountable teams to standard workflow and agreed upon process and outcome measures in order to achieve the triple aim of improved health, patient experience, and value.
Two major areas of focus for primary care are ensuring that all patients receive appropriate evidence-based screening and prevention services and coordinating the care of patients with chronic conditions. The former initiative will promote the general health and well-being of patients, while the latter is a key strategy for achieving better outcomes and reducing costs for patients with chronic conditions.
To achieve these goals while managing a busy practice requires that the authors leverage the PCP by engaging clinical and non-clinical team members in the care of their patient population. It is essential that each team member’s role be clearly defined and ensures they are working at the top of their scope.
This initiative was successful because of the compelling objectives, the buy-in generated by using Lean methodology and engaging the team in the design process, use of multiple feedback mechanisms including stories, dashboards, and patient feedback, and the positive impact on providers, staff, and patients.
McGough, P., Kline, S. and Simpson, L. (2017), "Team care approach to population health and care management", International Journal of Health Governance, Vol. 22 No. 2, pp. 93-103. https://doi.org/10.1108/IJHG-11-2016-0048
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