The role of patient care teams in chronic disease management

British Medical Journal, Feb 26, 2000 by Edward H Wagner

"In the gradual division of labor, by which civilization has emerged from barbarism, the doctor and nurse have been evolved"

Sir William Osier (1891)

The delivery of health care by a coordinated team of individuals has always been assumed to be a good thing. Patients reap the benefits of more eyes and ears, the insights of different bodies of knowledge, and a wider range of skills. Thus team care has generally been embraced by most as a criterion for high quality care. Despite its appeal, team care, especially in the primary care setting, remains a source of confusion and some scepticism.[1] Which disciplines are essential on the team? What do the team members other than the doctor do to support patient care?

With the ageing of the population and the advances in the treatment of chronic diseases, teamwork in the context of chronic diseases needs to be re-examined. Successful chronic disease interventions usually involve a coordinated multidisciplinary care team.[2-5]

In this article I consider the implications of these observations for the structure and functioning of patient care teams in primary care. My work is rooted in US health care, and the references and roles described largely reflect that perspective. I performed a Medline search for randomised controlled trials of team care using the MeSH heading "patient care team."

What is a patient care team?

A patient care team is a group of diverse clinicians who communicate with each other regularly about the care of a defined group of patients and participate in that care.[6] Do the typical staff members in a surgery--nurse, medical assistant, and receptionist--constitute a care team? The answer depends on how they function as a group--whether they meet, whether they explicitly define clinical roles, and what kinds of clinical roles they have. Starfield identified three categories of functions performed by non-medical staff: supplementary functions (functions that could be done, albeit inefficiently, by the doctor--such as giving injections); complementary functions (those that doctors often have neither the skills nor the time to do well, such as counselling on behavioural change); and substitute functions (those that are traditionally performed by the doctor, such as diagnosis and treatment of illness).[6] I will focus on the complementary functions. The real potential of team care to improve health outcomes and reduce healthcare costs is the ability to increase the number and quality of services available.

Effective team care for chronic illness often involves professionals outside the group of individuals working in a single practice; it may involve multiple practices--for example, primary and specialist care--or it may involve multiple organisations, such as a general practice and a community agency. Teams that cross practice or organisational boundaries may create communication and administrative nightmares but are essential for optimising care for many patients.[7]

Effectiveness of team care

Most successful interventions in chronic disease management entail the delegation of responsibility by the primary care doctor to team members for ensuring that patients receive proved clinical and self management support services.[2-4 8] Often the team is more effective with the addition of new disciplines, such as clinical pharmacy[9] or nursing case management.[8] Effective chronic illness programmes tend to exploit the varied skills of the team by using the following strategies.

Population based care--Population based care is an approach to planning and delivering care to defined patient populations that tries to ensure that effective interventions reach all patients who need them.[10] It begins with a protocol or guideline that defines the components (assessments and treatments) of high quality care. The steps required to deliver the interventions are specified and delegated to members of the team. Taplin and colleagues have described the planning and task delegation of population based care in a single primary care practice.[11 12]

Treatment planning--Treatment plans for each patient seem to be essential features of effective chronic illness programmes, and more formal, written plans help to organise the work of teams and help patients to navigate the complexities of multidisciplinary care. Plans that include patients' treatment preferences are more likely to result in satisfied, compliant patients.[13 14]

Evidence based clinical management--Advances in medicine have increased the number of chronic conditions that can be successfully treated but have also increased the complexity of regimens. The identification or addition of team members to achieve greater concordance with complex treatment protocols by providers and patients has significantly improved outcomes in several chronic conditions.[15-20] One major advantage of non-medical staff may be that the legal constraints placed on their decision making increase the rigour with which they follow protocols. Becker and colleagues, for example, compared the effects of lipid management by nurses with the effects of primary care on the lipid concentrations of high risk patients.[21] Even though both groups of professionals had access to guidelines and educational materials, patients randomised to the nurse intervention were 2.5 times more likely to reach their goal cholesterol concentration.