Team Based Care Assessment & Action Plan In the tables below, consider how fully each item has been implemented or functions in your practice. Circle the number that best reflects the completeness of implementation in your practice. If something is completely implemented, it means it is routine across the entire practice. If you are uncertain if something is implemented, or applies to you, circle the I don t know number. 1. CORE CONCEPTS Not at all Completely I Don t Know a. Planned Care: pre-visit checklist/planning, pre-visit labs, advanced/open access, etc. b. Standard Rooming Process: vital signs, exam room preparation, etc. c. Enhanced Standard Rooming Process: functional screenings, depression/anxiety screenings, patient agenda s, medication reconciliation, etc. d. Patient Care Team: the provider, care manager/coordinator, MA/RN, (core team) work together in a space allowing for continuous communication. e. Huddles: daily check-ins to review the day s schedule. f. Team Meetings: weekly, bi-weekly or at least monthly communication to focus on care gaps. g. Warm Hand-Offs: verbal communication in front of the patient between team members. h. Standardized Documentation: standard messaging, smart forms, and templates to promote accurate and consistent communication. i. Extended Care Team: utilizing members of the extended care team when appropriate (pharmacists, diabetes educators, case management, etc.). j. Team Approach to Non-Visit Patient contact: test results, nurse triage, patient phone calls/questions, medication refills, etc. k. On Time Start: minimize daily stress by starting on time each day 2. CORE PRINCIPLES a. Team Culture: the practice team is organized and works together to accomplish mutual goals. b. Empowered Staff: team members are able to perform proactively when caring for patients allowing for trust among the care team and improved job satisfaction. c. Critical Thinking: team members openly share and look for ideas to better meet patient needs and address gaps in care. Not at all Completely I Don t Know
d. Patient Population: the care team analyzes the empaneled patients in the practice to understand risk profiles, anticipate patient resources and develop/improve measures to support high quality patient care 3. TEAM-BASED CARE a. The practice QI team consists of multi-disciplinary members (MA/MD/RN/Administrators, etc.) b. The practice QI team model supports cross training when necessary. Training is provided for team members taking on new roles and responsibilities. c. The practice QI team regularly communicates in multiple methods to the practice and patients to encourage spread/sustainability of changes. d. The practice QI team utilizes PDSA s to test and implement changes. e. Protocols and standing orders have been implemented to better distribute workload throughout the team f. Every patient is assigned a personal clinician, with a small team to serve as back-up when the personal clinician is unavailable g. Patients and families can reliably and quickly access their personal clinician or care team to answer questions or deal with problems h. Care teams have been designated and have regular team meetings i. Team members have defined roles that makes optimal use of their training and skill sets (working at the top of licensure) j. The practice follows a risk stratification policy and procedure for identifying high risk patients k. Care teams utilize care plans that are developed with patients identified for care management Not at all Completely I Don t Know Practice Name: Name and Position: Date Completed:
Assessing Team Roles and Distribution of Tasks: EXAMPLE TEMPLATE Answer phone calls/triage TASK MA/RN MD FRONT OFFICE IBH OTHER Manage/triage provider inbox Primary point of contact for patients Patient outreach for overdue services, i.e. labs Patient hospital/ed follow-up outreach Patient notification normal lab/test results Patient notification abnormal lab/test results Pre-visit Chart planning Care team huddles participation Patient teach-back/motivational Interviewing Development of patient care plans Care Management for complex patients Medication reconciliation Screen patients for depression Provide Self-Management Support resources/tools QI activity participation Track/coordinate referrals Pre-authorizations meds/tests Patient check in/check out Care team lead Other:
Assessing Team Roles and Distribution of Tasks: DEVELOP YOUR OWN TASK
Assessing Team Roles and Distribution of Tasks: DEVELOP YOUR OWN TASK
Assessing Team Roles and Distribution of Tasks: DEVELOP YOUR OWN TASK
Assessing Team Roles and Distribution of Tasks: DEVELOP YOUR OWN TASK
Develop an action plan to address gaps in your Team-Based Care approach. This may include assigning or re-assigning roles and re-distribution of tasks. Using the results of the team-based care assessment and the distribution of tasks worksheet, prioritize areas of opportunity in an action plan for improvement. Start with the obvious gaps, ask the following: 1. Is the plan worth doing? 2. Is the plan specific and measurable? 3. How will the result of this plan improve patient outcomes/satisfaction? 4. Are the outcomes inclusive of provider/staff satisfaction? Gap in Team- Based Care Model Goal Barrier(s) Specific Task(s) Responsible Party Timeline