Welcome to Service Transformed: Lessons in Veteran Centered Care. For this final unit, we're going to talk about the principles of team based care. The objectives here is really to understand how team based care works in the healthcare environment, and then we'll focus on in segment two, the patient center medical home, or what's that type of care called within the VA healthcare system, the patient align care team. So what is a team? A team has a very simple definition of two or more people working together. It's really about the interdependency of those people working. It's about a collective effort and synergy and the issue around the synergy is similar to the braid you see in this picture that really the whole is much greater than the sum of it's parts, it's much stronger. When you think about team based care it's really about using a small group of individuals working within the healthcare environment, who have a collective identity, usually around the patient and the patient's gold. They have a shared responsibility about the patient or a group of patients, and examples are actually quite rampant in today's healthcare environment, rapid response teams, palliative care teams, primary care or operating room. These are the places where you can see highly functioning teams that are really there focused on the patients' needs. We'll talk a little bit about our question, but here is a question for you to think about as we go through this module, which types of following care locations are included in a primary care medical home, is that a large integrated health system with geriatrics, all hospitals, for profit clinics or emergency rooms? So when you talk about team based care, the idea is about all of the professionals and many of the services a patient needs are all available at one point of content. It is all the professionals and others that are practicing at the full extent of their license, really geared towards helping patients optimize their health. Now, you often seen team based models in chronic care places. But also in acute care teams, as well. Then, another thing to keep you thinking about what we're going to talk about is which healthcare professionals are involved in team-based care? Emergency/disaster responders, hospital-based providers or home-care providers or all of the above. When we start talking about team based care there's some actually very interesting principals and research done about this idea about why this is important to know, how it optimizes outcomes. And team steps is this integrated government supported program that now you can find through the Agency of Healthcare Quality Research, but really started as a study team within the Department of Defense, saying how can we optimize team dynamics? It's been a long history over the last 20 years looking at how we actually optimize team outcomes in order to provide better care. And here you can see a nice timeline showing really how team training and patient safety became really hand in hand as the ideal model for communicating patients in our care. But also ensuring that that care is safe. TeamSTEPPS is again is a strategy that's really based on 30 years or more of experience. It's about team training programs that have been shown to improve attitudes, increase knowledge and improve skills. And Salas actually have done a nice meta-analysis that did show a positive effect of team outcomes. Moderate, however, in the right direction. But when you want to think about what makes up team performance, it is those three things that I just talked about. You want to optimize the knowledge, skills and attitudes of all members of the team. You want to enhance their situational awareness so they understand what's happening in regards to themselves, their teammates and the patient, you want to enhance communication, look at leadership and mutual support. A code team is actually a classic example of someone has to take charge in a code. But actually all the people involved be it the nurse, the pharmacist, the physician, the tech, who might be helping the respiratory tech, anesthesiologist, etc., they're all there with one goal in mind to take the best care and safe care of our patient. When you look at team competencies, as we've talked about, you really wantna think about this idea of having a shared mental model. I think most of us have great experiences about thinking about teams as it relates to sports. Everyone has a clear goal in mind. And everyone is marching towards that goal. That's no different in healthcare. So in healthcare we need to make sure that our teams have a shared mental model. That we trust each other, that there's an orientation at the beginning, you'd be amazed at how efficient understanding what people's names are, what their roles are, and any concerns that they might have. If you can deal with that in the first bit or an open space in terms of a huddle, you can actually optimize team performance in terms of patient care. I mean, it really allows you to provide safe care that's efficient and allows you to adapt to situations that are unanticipated. So Salas and Zach also came up with this idea about what a high-performing team looks like. And again, just to reiterate, we talked about this idea about what shared mental models they might have. They have clear roles and responsibilities. There's an engagement around regular feedback between team members and that is the process that actually helps develop a collective trust and optimizes outcomes. Here's another schematic to sort of, look at team base care from Mitchella and colleagues. Again, these principles don't change despite who might be looking at how do you optimize healthcare teams. Meaning you have to have shared goals, clear roles, effective communication, trust and then you want to measure an outcome. As we think about healthcare reform, and specifically the Accountable Care Act, this was the first time that legislation clearly said that team-based care was part and parcel of what we need to provide high quality healthcare. But you have to ask, we all have individual professional training schools. We have medical schools, pharmacy schools, nursing schools, schools of social work or public health and what does that actually mean if we want to produce highly performing team members when we have separate education modalities. So our colleagues at the Medical College of South Carolina, really came up with a conceptual framework about advancing this idea of interprofessional education. And they talk about this idea that team members, no matter what profession they might identify with, need to enhance their actions, practice skills, think collaboratively as a team member and prepare. That skill set has to go on at the same time that you're transforming knowledge so that the knowledge is contextual so that people are practicing in teams that make sense to them under going exercises that provide the right context in terms of healthcare. There is some independent knowing or knowledge that each individual must have to bring to the team. That you have to have transitional knowing and absolute knowing and it's really this idea of how do you create collaborative care? It's really about using, applying and demonstrating one's knowledge and working as a team. So if we think about this, the World Health Organization actually has spent quite a bit of effort thinking about teen based healthcare. And collaborative practice can improve in which of the following situations. Access to or coordination of healthcare services, appropriate use of specialists clinical resources, health outcomes for people with chronic disease or all of the above. Which one of these or all of these really identifies what collaborative practice might mean. We can actually think about this entire idea about Team Based Care as we also think about a Veteran-Centered Approach. So as we've been talking about throughout this Coursera course is, the vision is really the VA will be Veteran-Centered. It eases the access and service the positive interaction with all veterans, both within the VA system but also within civilian healthcare providers that we say that no matter how a veteran might enter healthcare, either that there was no wrong door. So even though they might have engaged with the VA through benefits services that when they needed to access healthcare people can give them that information. It allows all these contextual knowledges or the understanding of the external linkages between civilian, the Department of Defense and VHA health services. There's a centralized architecture so you can gather data. And that there's really warm hand offs people so think about this as team. All of these people have different roles as one might approach a veteran who's seeking healthcare but they all must come together to really provide a better and centered approach. So another question would be, which of the following are core principles of team-based care? Shared goals of team and patient, focus on expanding practice, ability to take on more patients, or this idea about individual goals. So again, as you want to think about what does it mean to get a workforce of health professionals ready for collaborative practice in terms of interprofessional education. There's things that we can do as educators, whether we are faculty or peer to peer training and there's things that the curriculum must have in place in order to ensure that once a health professional is out on the other end, that they actually can practice collaborative care. So there's educator mechanisms in terms of staff training, there's people who are really excited about this idea of interprofessional education such as champions, there's institutional support. So at a place like the University of Michigan we have developed a center for interprofessional education so that all of the schools can report together and come up with common and shared learning goals and objectives. And then, there's basic curriculum mechanisms when you think about logistics. How do we make sure that the Social Work students and the School of Public Health students can take a class together? What is that material that needs to be in that class? Are we all focused on the same objectives? Are we really using adult learning principles? So again one of the advantages of being in a professional school is that we are dealing with adults who like experience-based learning that really pushes them to the boundary. We want to make sure that we use those principles. We want to asses things, test our ideas about to learning that individuals might have. So we want to make sure that we have assessments that go along with our learning and we want to make that learning contextual. So here is an example. Hand offs is something that happens every day in the healthcare environment. And it's really often a team based care. I might be handing off to another colleague, I might be taking a report from a nursing colleague, I might be asking a member of my team, such as the pharmacist to help me take care of a patient. And this idea of how do you actually go about handing off information is critical. It's really about patient safety. You want to make sure the hand offs are organized, that just about communication, that everyone understands the communication path. How you want to articulate the needs of cross-cover so if I need you to do something, I need to be clear about what that is and then what the anticipated consequences of that care might be. And then you want to assert yourself. because I might say, Jill, I really didn't go to agree with you in terms of what that plan is. And so, we can have a back and forth with some feedback about how to actually best take care of that patient. So again, if we think about the team based healthcare principles in values we want to ensure that the patient and the family are in the center of the team so it is not about us as healthcare providers so this is really about the patient and their family and what those goals are. We want to match what resources the patient needs to the resources of the team. We want to build bridges across. This might be across the typical healthcare silos of disciplines, but also the silos of in-patient and out-patient care. And we wanted to find a coordinated research agenda, so that we can further really understand how to optimize high value team based healthcare. I think our knowledge is still relatively new in this area and I think more models and your own investigation into this area will actually help contribute to patient safety and the quality of care that we give to patients and our veterans. So if we wanted to think again about this question, about which of the following are core principles of team based care, we've shown that shared goals of the team and patient really is the key here in terms of the answer. Again, when we think about which of the following healthcare providers that could be involved in team based care, I hope I've shown you that actually any of these providers could be actively engaged in high performing teams, whether in the emergency room, in the hospital or at home. So what we've covered here in terms of team-based care, is this idea about what does it mean to be a member of a team, how do we learn together, what are the principles of high performing healthcare teams? And what do we need in terms of structuring curriculum and activities as learners go through their healthcare training or even afterwards to ensure that we are really patient-centered or veteran-centered in our focus?
