Expanding Team-Based Care Roles to Successfully Support Transitions of Care: A Mini-Case Study

In an era where healthcare costs are high, it is essential that primary care practices address utilization of the hospital and provide appropriate follow-up and preventative services for the patients. Armed with this knowledge, a HealthTeamWorks practice facilitator assisted six primary care practices in developing transition of care processes. Most importantly, the workflows have sustained through staff turnover and leveraged the strengths and skills of all team members, keeping patients from hospital readmission and reducing healthcare costs.

In line with HealthTeamWorks transformation methodology, the practice facilitator began by gaining a better understanding of each practices’ current process related to transition of care and developed a clear vision and goal for transition of care for patients. By starting with current processes, the practices quickly realized they were not proactively providing transition of care services and weren’t impacting hospital readmissions for their patients. Armed with this knowledge and the use of Quality Improvement (QI) tools, the practice facilitator led the creation of practice-specific workflows that engaged the ensure team. Everyone was involved, with the core tasks revolving around the Care Manager and Medical Assistant (MA) to outreach to patients discharged from the hospital.

Transition of Care (TOC) included the following aspects:

1. Gained access to Colorado Regional Health Information Organization (CORHIO), the eastern CO Health Information Exchange (HIE) to receive notification of patient discharge.
2. In partnership with each practice, the facilitator developed a patient centered script for the MA and care manager to use in their transition of care phone calls.
3. The facilitator conducted role plays using the script to ensure all team members were involved and confident in their support.
4. Conducted development and assessment of team-based workflow for transition of care activities. Not only was a workflow developed, but it was tested with significant turnover of the individuals in the MA role. When the new MAs were hired into the roles, the transition of care workflow became a part of their job, creating further excitement, and resulted in a deeper engagement of the MA within the care team.

Using evidence based guidelines and QI methods, the HealthTeamWorks facilitator supported each practice based on their staffing structure, their patient population and their comfort level. The complex tasks of reducing healthcare costs lay within all primary care team members with HealthTeamWorks as core member of the efforts.