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Interprofessional Team-Based Care 

Interprofessional Team-Based Care
Interprofessional Team-Based Care

Beverly Lunsford

and Terry A. Mikovich

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Longevity has increased substantially in the past 50 years, and the fastest-growing segment of the population is people over 85 years of age. Along with increased longevity is an increase in chronic illness. In 2012, about 50% of Medicare beneficiaries (older adults and disabled) in the United States had at least one chronic condition,1 25% had more than one chronic illness, and 20% had five or more chronic health conditions.2

Chronic illnesses are associated with intermittent and/or progressive functional decline, requiring regular monitoring, disease management, and coordination of care. Multiple providers across settings help prevent, delay, or minimize decline in health and maintain quality of life. Older adults with functional limitations need personal assistance for activities of daily living (eating, bathing, dressing, toileting, and walking) as well as instrumental activities of daily living (shopping, medication, financial management, and housekeeping). These services can enable people with functional disabilities to live safely in their homes as long as possible.3

Health care systems are being redesigned to address the unique needs of older adults and individuals with chronic illness. The current health care system was developed in the early 1900s for short-term illness (e.g., acute infection, heart attack, trauma). Now the most common illnesses are noncommunicable diseases, such as coronary artery disease, cancer, diabetes, and dementia, which are chronic and long-term illnesses that may cause progressive loss of functioning and cognitive capacity over many years. In addition, people over 60 experience disability from age-related hearing loss, visual loss, frailty, and movement difficulties.4 These conditions require a different care system that includes primary care, acute care, specialty care, rehabilitative and long-term care, and community resources and supportive services.

Realigned systems of care for older adults require many health care professionals from different specialties and disciplines, such as cardiology, nephrology, endocrinology, ophthalmology, and social work. Older adults traverse several levels of care, from primary to acute and rehabilitative care and community-based services, requiring timely and effective communication to achieve optimal outcomes. Each provider, individual, and family needs comprehensive information about other conditions, hospitalizations, and specialty care for making immediate health care decisions. Practitioners cannot provide care for just a select condition(s), as it may not be independent of other issues/problems. This could result in increased costs from duplication of services and prescriptions, unnecessary hospitalization, and/or longer periods of illness.5 In addition, many people utilize complementary and alternative therapies, so practitioners need a greater awareness of their value.

Seamless and accurate flow of information throughout the system of care, including the individual and family, ensures the integration of all relevant components and informed decision making to optimize outcomes. A primary health provider who knows the older adult well can facilitate addressing mind, body, and spiritual needs and coordinating care with a team of practitioners. This approach is person-centered and enables the team to gain a greater knowledge of the social determinants of health that may impact the individual’s health and well-being.

Interprofessional or Interdisciplinary Teams?

The terms interdisciplinary and interprofessional are frequently used interchangeably when referring to teams, but there is an important distinction in function. Interdisciplinary team members work within the roles and abilities of their discipline, and clinicians run the risk of being isolated to their own professional standards of care. The complex needs of older adults with chronic health conditions require the different disciplines to work and communicate more effectively. Interprofessional care means that each member utilizes knowledge, skills, and attitudes to augment and support the contributions of other members of the team.6 Each health care team member seeks knowledge about the role of other professions involved to provide integrated, continuous care for the older adult and his or her family, while promoting a person-centered approach that decreases duplication and fragmentation, reduces costs, and results in better outcomes. Team members are held equally accountable, and they work cohesively to share information from their unique perspectives with peers without fear of criticism or dismissiveness.7

Team-based care may be difficult to define because it occurs within different settings, as well as across settings.8 There are primary care and home-based teams, acute care or hospital teams, emergency response teams, and so forth. Teams may include different constellations of team members, and they may interact through different modes, such as face-to-face or via medical records, phone, or email. In addition, teams can be geographically dispersed.

Teams function more effectively if they have a common goal focused on the individual and his or her family, including optimal physical functioning and quality of life. Team members should address their individual and organizational needs so they do not distract the team from the individual as the primary focus of the team’s collaboration. Professionals on the team should be experienced in the clinical fields pertaining to the client’s diagnosis, and during team development, time must be spent on learning about the other professions involved. Many professionals do not learn about other professions’ knowledge, skills, and roles in client care during their educational process, so they may lack fundamental knowledge of how other professions contribute along the health care continuum.

While decisions are made as a team, there may be an identified leader who facilitates communication and engages team members regularly to promote a smooth process for collaboration, or at critical times for problem-solving. A leader creates an atmosphere of trust to achieve the primary goal. However, when teams are widely dispersed across several settings, the “leader” may change depending on the current site of care or critical problems being addressed. A formal leader also facilitates team formation by establishing mission, policies, and procedures.

A new role of care coordinator or geriatric case manager is emerging to coordinate care within and across settings. The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberate organization of patient care activities between two or more participants (including patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services. Organizing care involves marshaling personnel and other resources needed to carry out all required patient care activities.”9 These may include negotiating responsibilities, facilitating transitions, assessing needs/goals, creating a proactive plan of care, monitoring, following up, responding to change, supporting self-management, and linking the patient and family to community resources.

In the United States, financial incentives have been implemented for care coordination and interprofessional collaboration for individuals with complex health needs to improve health outcomes, prevent hospitalization, and reduce the cost of care for older adults.10 As of January 2015, U.S. physicians are able to bill monthly to provide care coordination for individuals with two or more chronic conditions.11 This includes non–face-to-face chronic-care management services, such as consulting with other providers who care for the same patients, coordinating care with home and community-based clinical providers, and communicating with caregivers/decision makers (i.e., family members) to ensure that the right care is being given, at the right time, and in the right setting.12

The Dartmouth Report has observed patterns that indicate that it may be more difficult to achieve goals of coordination in some regions than others.13 An example is that the volume of services required based on contact days and inpatient days presents a higher level of difficulty in care coordination. In the Chicago region the average number of inpatient days is 5.3 to 7.6 per Medicare beneficiary compared to the Wyoming region, with 3.8 to 4.3 days.13 p29 New payment models like primary medical homes and comprehensive primary care require care coordination, but in some regions the specialists may play a more prominent role, whether they are aware of it or not. Older adults or family members may need to discuss this with the care providers to determine who will be responsible for helping them coordinate care as they age.

For older adults utilizing long-term care services (e.g., nursing homes, assisted living, or home care), the health care team may include physicians, advanced practice nurses, nurses, physician assistants, physical therapists, occupational therapists, social workers, dietitians, art therapists, and activities coordinators. For optimal care, each service provider needs to be aware of the core clinical skills of other providers and how their services align with team goals and expectations to provide person-centered care. This is exemplified by the case of an older adult who experienced a stroke for the first time and receives services from a neurology team, a physician, an advanced practice nurse, nurses, physical therapists, occupational therapists, speech therapists, a dietitian, massage therapists, and expressive arts therapists with recommendations for medications, food intake, activity therapies, and arts engagement (for meaningful activity and stress reduction). If changes in levels of activity, medication, food tolerance, and the individual’s and family goals are not communicated among the team members, this could result in negative clinical outcomes, such as inadequate management of blood pressure, duplication of services, depression, and lack of client and family ability to follow through (participate) with care.14

Transitions between care settings (i.e., home, nursing home, assisted living, and acute care) are particularly vulnerable times for older adults, and they can benefit from interprofessional collaboration. Transitions may involve different systems of care (transfer to emergency room from long-term care), different health care providers and teams (outpatient clinical services and long-term care facility), and changes in treatment protocols and needs (e.g., stroke precautions) when moving to different units in the hospital or discharge back home. Some of the common barriers and problems include lack of a person-centered focus, lack of feedback or information between specialists and primary care providers,15,16 difficulty obtaining medical records and laboratory results on the part of providers,17,18 and lack of hospital follow-up with home discharge,19 which is commonly referred to as a “Swiss cheese” model. Collaboration and communication that allows smooth transfer of information is needed among all levels of the team while maintaining a focus on the individual’s needs, fears, and preferences.

Two evidence-based models for integrating systems of care are the transitional coaching model (TCM)20 and the care transitions program.21,22 For older adults who are transitioning from hospital to home, the TCM is a good example of interprofessional collaboration for safe transitions. This model focuses on hospital discharge of people with chronic illness. Advanced practice nurses make inpatient visits and then post-discharge home visits with additional phone consultation. The nurse forms a partnership with the individual and his or her caregiver and coordinates care with physicians, nurses, pharmacists, and social workers. This model has demonstrated significantly lower rates of repeat hospital admissions, deaths, and total costs for the intervention group versus the usual care group.

The care transitions program proposes two opportunities for improving care coordination: patient activation and a coach to manage care coordination. In this model, the coach (an advanced practice nurse) works with the patient and family members so they can coordinate their own care. The coach teaches the individual and family members, which promotes independence and a greater competence in self-care skills. This model was associated with reduced hospital admissions for the same condition and reduced costs of care at 6 months after discharge.

Interprofessional Team Models

There are several emerging models of team-based care reflecting the unique needs of older adults for maintaining well-being, managing multiple chronic illnesses, and/or frailty.

Health-Oriented Teams

The first two examples in integrative geriatric care are the health promotion model and the disease-oriented team.23 The health promotion model may include a health-oriented team that works with individuals who may seek to reduce stress, maintain optimal weight, or manage pain. The interprofessional team for weight management may include the primary care provider, a nutritionist, an exercise physiologist, a mindfulness eating instructor, an acupuncturist, and a spiritual guide.

In contrast to the health promotion team is the disease-oriented team, in which the focus of care is for the person experiencing major health problems, such as cancer or renal failure. The team for renal disease, for example, may include a nephrologist, a dialysis technician, a surgeon, a pharmacist, a renal nurse, a mind–body coach, and a spiritual director. This provides an integrated approach using traditional disease management with holistic mind, body, and spirit care that is person-centered and promotes quality of life.

In the 1990s, integrative medical clinics began opening in academic medical centers (e.g., University of Arizona, University of California at San Francisco, and University of Maryland) to provide integrative care.23 Integrative medicine centers have since added complementary and alternative medicine (CAM) centers.24 During this time, other integrative medicine clinics have evolved outside of academic centers, such as at Scripps and the Beth Israel Continuum Center.

Integrative medicine teams are also established in acute care settings. A 2010 study of U.S. hospitals found that 42% offer one or more CAM therapies.24 This is in comparison to 37% in 2008 and 26.5% in 2005. Hospitals attribute this rise in offering alternative therapies to patient demand (84%) and clinical effectiveness (67%) These services can significantly increase the number of disciplines represented in team-based care, as the services may include art therapy, yoga, tai chi, meditation, acupuncture, chiropractic, and so forth. It is imperative that CAM providers gain a good understanding of the other disciplines, including defining terminology, sharing medical system theories, and patient communication. Similar to other team-based care, this requires a cultural shift for physicians to move from a traditional model of “all-knowing” to a “shared knowledge” model for team care.25

Home and Community-Based Services

Home and community-based services, a subset of long-term services and supports, provide care and service coordination outside of institutional settings. They include supports for individuals, their families, and other unpaid caregivers to maximize the person’s independence in the community. For the first time, home and community-based services accounted for a majority of Medicaid expenditures for long-term services and supports in fiscal year 2013, and given the need for promoting independence and well-being for older adults outside of institutional settings, this expenditure is expected to grow.26

Home-Based Primary Care

Home-based primary care is an interprofessional team-based model of care that focuses on the 5% of older adults who are most ill and who represent almost 50% of Medicare expenditures.26,27,28,29 These patients are more likely to be older, with multiple chronic conditions, and they enter skilled nursing facilities at a higher rate.30 Home-based primary care includes medical and social services for seniors who are unable to or find it difficult to get to an office for medical care. There are more than 150 home-based primary care sites in the Department of Veterans Affairs (VA), and they are reported to reduce hospital and nursing home usage, with 24% lower total VA costs and 11% lower Medicare costs.30,31 The VA home-based primary care teams include physicians, nurses, social workers, dietitians, psychologists, pharmacists, rehabilitative therapists, and other professionals who provide integrated care. The team coordinates care with each other, the patient, and family caregivers (if available) and provides referrals to other needed services and resources outside of the VA.31

To test the effects of this model in the Medicare fee-for-service area, a case-controlled concurrent study of 722 home-based primary care cases and 2,161 controls matched for sex, age bands, race, and Medicare buy-in status, long-term nursing home status, cognitive impairment, and frailty examined Medicare costs, utilization events, and mortality.32 The mean age was 83.7 years for cases and 82 years for controls, and a majority of both groups were female (77%) and African American (90%). After 2 years of follow-up the cases had lower Medicare and hospital costs ($44,455 vs. $50,977 in controls and $17,805 vs. $22,096 in cases), lower skilled nursing facility costs ($4,821 vs. $4,098), higher home health costs ($6,579 vs. $4,169), and higher hospice costs ($3,144 vs. $1,505). The cases had 23% fewer subspecialist visits and 105% more generalist visits. Overall, the cases had 17% lower Medicare costs over 2 years with no difference in mortality or time to death between cases and controls. Thus, home-based primary care results in lower Medicare costs with similar survival outcomes.

An additional advantage of home-based primary care in the VA is that there is no end date for the care. Consequently, at times the patient will transition to hospice. When a need for the hospice level of care becomes evident, the provider, nurse, and social worker will meet with patient and family/caregiver to discuss hospice. If needed, the psychologist can participate in the meeting. If the patient agrees, a referral is made to hospice. The home-based primary care team continues to provide primary care and collaborates with the hospice staff.

Acute Care for Elders

An Acute Care for Elders (ACE) unit provides an interdisciplinary model of care in acute care settings that includes the proactive identification and management of geriatric syndromes with teams that focus on person-centered care. The teams may consist of geriatricians, nurse practitioners, nurses, rehabilitation therapists, pharmacists, dietitians, care managers, and social workers who work collaboratively to develop patient-centered care plans. Care transitions are planned from the day of admission with communication of care plans to the caregivers, including physicians, nurses, family members, and the patient. Care includes consideration of environmental modifications that enhance safety, mobility, and cognitive stimulation and provide a more homelike atmosphere.

The ACE unit may include the use of contrasting colors for individuals with low vision, handrails in rooms and hallways, furniture adapted for easier transfer, and a central gathering place for group activities. A randomized controlled study of 1,632 older adults indicated that individuals in ACE units had a significantly shorter length of stay (6.7 days per person vs. 7.3 days in usual care). This reduced the total inpatient costs from $10,451 per patient receiving usual care to $9,477 per patient in an ACE unit. In addition, patients were able to maintain their functional abilities, and hospital readmission rates were not increased.33

Comprehensive Geriatric Assessment in Acute Care

Another model of care for older adults in acute care settings is a dedicated team of geriatric specialists who provide consultative services across the institution instead of a dedicated geriatric ward. The effectiveness of these multidisciplinary specialist wards versus specialist teams in acute care hospital wards was shown in a meta-analysis of 22 randomized controlled trials with a total of 10,315 patients across six countries, in which older adults who received comprehensive geriatric assessment (specialist teams on dedicated hospital unit) were more likely to be alive and in their own homes up to a year after admission, compared to older adults who received general medical care.34 In addition, older adults who received comprehensive geriatric assessment were less likely to be institutionalized, less likely to die or experience deterioration, and more likely to benefit from improved cognition.

Program of All-Inclusive Care for the Elderly

The Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive medical and social services for frail individuals so that they can live safely in the community. PACE includes integrated preventive, acute care, and long-term care services that address the frequent complex medical, functional, and social needs of frail older adults. PACE provides flexibility for clients, family members, caregivers, and health care professionals to meet the person’s health care needs. Patients over age 55 who are eligible for nursing home care may join this comprehensive service program to remain in the community.35

Most participants are dually eligible for Medicare and Medicaid benefits. PACE provides an interdisciplinary team of health professionals with the sole source of financing from Medicaid and Medicare benefits. It enables practitioners to provide participants with all needed services rather than only services reimbursed by Medicare and Medicaid fee-for-service plans.

It has been difficult to conduct experimental studies to measure the effectiveness of PACE due to the limitations of finding an appropriate comparison group. A review of research for PACE programs indicate that there is no significant effect on reducing Medicare costs, and PACE programs may increase Medicaid costs.36 While enrollees may have fewer hospital admissions, they may have higher rates of nursing home admission. There may be improvement in quality of care for older adults, indicated by lower rates of pain and lower mortality rates. PACE enrollees express satisfaction with medical and personal care.

Palliative Care Teams

Palliative care teams address pain and symptom management for individuals with acute or chronic medical conditions and their families. A dedicated palliative care team offers medical, nursing, social services, and chaplaincy, in addition to coordinating other therapies (CAM, physical, occupational, and speech therapy) that address specific needs. Similarly, hospice provides an interdisciplinary team that includes doctors, nurses, therapists (speech, occupational, and physical therapists), home health aides, social workers, chaplains, counselors, and trained volunteers. Integrative and complementary medicine specialists may be part of both palliative and hospice care teams to provide pain and symptom management, support and education for the family and caregivers, as well as an opportunity for the dying individual to find a sense of transcendence and peace with dying.

Interprofessional Team Training

The Partnership for Health in Aging (PHA), a coalition of more than 30 organizations representing health care professionals who care for older adults, developed a position statement to inspire the development and expansion of academic and continuing education to provide interprofessional team training.37,38,39,40 The education must include attitudes, beliefs and experiences about providing team care; the differing commitment of faculty and students from different disciplines to the training; the value of education by matching the level of student education and interprofessional experiences in the clinical setting; less hierarchical clinical settings with shared leadership among health professions for more effective student education; and institutional and financial support for education and practice settings for meaningful interprofessional training.

The Agency for Healthcare Research and Quality (AHRQ), in collaboration with the Department of Defense’s Patient Safety Program, has developed a comprehensive curriculum for teaching team care, TeamSTEPPS.41 It is designed to improve the culture of safety in medical teams that is rooted in 20 years of research and lessons learned in applying the principles of team care. The curriculum is designed for different settings of care and aims to increase the awareness of team functioning, clarifying roles and responsibilities, resolving conflicts, improving information sharing, and eliminating barriers to quality and safety. AHRQ engages groups of professionals within organizations in the training to improve patient safety by building more effective teamwork across their organization.

The Interprofessional Education Collaborative fosters opportunities for health professions students from different disciplines to learn about, from, and with each other.42 This collaborative has developed core competencies to guide health professions education in team-based practice to foster greater collaboration and better health outcomes.


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