In our last blog post, we looked at some of the things that can get in the way of a care team optimizing patient care:
Roles may not be as clear as they need to be. Providers may be carrying too much of the work. Staff may not be working to the full extent of their abilities and training. And organizations may have plenty of information about their patients without a consistent way to use that information to proactively trigger the most impactful actions.
Once you start seeing those problems, the next question is fairly simple:
How do your workflows help to perpetuate your organization’s problems?
Before changing a workflow, we need to understand it.
That means talking to the people who are doing the work every day.
Employee surveys can help answer some of those questions. So can organizational data, workflow reviews, and conversations with staff and leaders.
Once the current workflow is clear, the next step is looking at who is performing each task.
Instead of thinking of these as new roles, it’s more about helping existing roles reach their full potential by understanding how each relates to the roles of others and to the workflows that direct work to one member of the team instead of to another.
In defining care team roles, clarifying how one role relates to another is key to care team development.
This is where care team development can either become practical or become another initiative that merely looks good on paper.
The people who work the process every day usually know where the problems are.
They know which steps take too long. They know where information gets lost. They know which responsibilities keep falling back on the provider. They know when the provider could be doing more to help patients solve problems and achieve better outcomes. They also know which changes are likely to work in the real world.
Their experience matters and can inform the way you structure care.
So when we work with a Health Center, workflow design needs to involve the people who will actually use and embrace the new process.
That might mean changing who handles certain tasks. It might mean creating a more consistent way to prepare for patient visits. It might mean establishing regular team discussions around patients and care plans. It might mean creating clearer expectations around when another member of the team should become involved.
The goal is to make it easier for the team to coordinate the work they’re already doing by making workflows and roles more intentional and more explicit, ultimately resulting in improved patient care.
Most Health Centers already have a tremendous amount of information about their patients.
The opportunity is to make that information useful at the point when it can actually change care.
If the EHR shows that a group of patients is overdue for a particular screening, the team needs a way to identify those patients and determine what happens next.
If patients with certain chronic conditions are not meeting their care goals, someone needs to know who they are and what kind of follow-up would help.
If a patient repeatedly misses appointments, the team may need to understand what is getting in the way and whether another form of support is needed.
The data doesn’t solve those problems on its own.
It gives the team a place to start.
The important part is building data workflows that put relevant information in the view of providers at the point of care, and use population health triage criteria to automate task triggers.
When we work with a Health Center, we start by looking at how care is actually being delivered, not just how the process is supposed to work on paper.
We talk with the people doing the work, look at the data, and identify where the current model may be creating unnecessary work or making it harder to provide the care patients need.
From there, we work with the organization to make practical changes.
That might mean redefining roles so that people are working at the highest level appropriate to their training. It might mean decreasing staff, especially in roles that do not meet patient needs or fit within the team model. It might mean changing how the team prepares for a visit or how information moves between the PCP, CMA, Care Coordinator, nurses, and dental and behavioral health staff.
And it may mean developing a more consistent approach to using population health data to identify patients who need attention.
The specific changes depend on the organization, but development of impactful care teams starts with the core principles of shared ownership of patients, work at the top of licensure, integrated behavioral and dental health whenever possible, and the use of population health management data and methods to prioritize resource deployment and address patient needs proactively rather than reactively.
At the end of the day, the success of a care team development effort must be measured in process and outcome improvements, not how thoroughly the org chart has changed.
Those are the things that matter. A care team should make care feel more connected, not more complicated.
A new workflow is only useful if people can actually use it.
Teams need time to adjust. Leaders need to understand what’s working and what isn’t. Data needs to be reviewed. And sometimes a process that looks good during planning needs to be changed once it is implemented into patient care.
Care team development isn’t a one-time project to create a workflow, hand it to the staff, and move on. Success comes through follow-through and ongoing revision.
At THRIVE, we work with Health Centers throughout the care team development journey, from understanding the current state of operations to building more proactive approaches to care through redesign of roles and workflows, while simultaneously embedding ongoing improvement processes into the model.
If your Health Center has invested in team-based care but feels there is still a gap between the model you have and the model you want, that gap is worth exploring.
If you’re ready to take a closer look at your care team, THRIVE can help you identify where the current model is falling short and help you build a practical path to more impact.
