Team Based Care


Moving toward value-based payment models, where reimbursement is tied to quality of care and measured by patient health outcomes, requires changes in workflows and ways the care teams work. Team-based care is not only vital in addressing each patient’s unique goals and needs, it is also an integral component to competing and succeeding in the value-based payment landscape.

Christie Abdul-Greene, Market Manager for Practice Transformation and Value Based Care with CHI Health Clinics in Nebraska and Iowa shared with us how the changes CHI Health University Family Medicine and Residency clinic made to engage patients and staff have resulted in improving patient outcomes.

What did you want to change, and why? (In the words of University Clinic Team)

Our team was concerned with the percentage of patients who had uncontrolled A1C levels and continued to struggle with their diabetes management. We wanted to improve our approach to diabetes management by engaging both patients and staff. With reduced patient volumes due to the pandemic in late spring of 2020, clinic teams utilized this time to take training on an integrated team approach to help manage the A1C patients. 

What were the changes you implemented?

We created a comprehensive pre-visit planning process and added standing orders to identify patients with elevated A1C rates. We are lucky to have an integrated pharmacist and pharmacy students through our academic partner, Creighton University. They support the team by reviewing information on patients with elevated A1C levels and create plans with recommendations and guidance on medication changes. In addition, we collaborate with our Population Health Coaches, Certified Diabetes Educators, Providers, and Behavioral Health Specialists to identify diabetic patients with higher A1C levels.

What tactics do you use to engage your team?

Our clinic holds morning and afternoon huddles where teams highlight and review areas of focus for the week. During these huddles we discuss the importance of ensuring Patient Snapshots are reviewed and pre-visit plans are completed. These huddles also include daily reminders of A1C and other care gap report reviews. Proper pre-visit planning helps us ensure providers can address and add orders if needed during face-to-face and virtual visits. If orders are not needed, everything is able to be done in the scheduled appointment. Utilizing an integrated team approach the front desk staff assists in scheduling follow-up appointments for patients as well as providing outreach where needed.   

CHI Clinics have created an “A1C” magnet to be placed outside the examination room to notify providers that the patient is due for the A1C check.

What were the impacts of the improvements?

We saw an overall decrease of approximately 6% in the number of patients with uncontrolled A1C levels. We consider this a significant change and are thankful we can partner with our patients in improving their overall health. We are especially excited as we serve a diverse population of refugees, individuals who lack housing, LGTBQIA patients, students, and about 40% dual eligible patients. As the next step we have enrolled some patients struggling with their diabetes to Longitudinal Care Management. This step has helped in prioritizing focus on high-risk patients to ensure they have the needed support in place to improve health.

Have you seen any effects on the team satisfaction and/or efficiency?

The team does feel successful and satisfied when they see that the patients they care for have better outcomes. They know that the creative ideas that they came up with to better serve and engage patients has had a real impact. 


This interview was conducted by Angie Schindler-Berg, Practice Facilitator at HealthTeamWorks.



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