Team-Based Care in the Literature

A number of studies and articles have shown the value that team-based care can add when it comes to managing chronic conditions. Below are selections that highlight best practices, as well as specific studies detailing improved outcomes in the management of heart failure and diabetes patients.  



Best Practices

Mitchell PM, Wynia R, Golden B, et al. Core principles & values of effective team-based health care. Discussion paper, Institute of Medicine, Washington DC. 2012. 

This discussion paper provides the importance of team-based care, best practices to implement it, and defines values, terms, and goals. 

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Wagner EH, Flinter M, Hsu C, et al. Effective team-based primary care: observations from innovative practices. BMC Family Practice (2017) 18:13. DOI 10.1186/s12875-017-0590-8

Team-based care is now recognized as an essential feature of high quality primary care, but there is limited empiric evidence to guide practice transformation. The purpose of this paper is to describe advances in the
configuration and deployment of practice teams based on in-depth study of 30 primary care practices viewed as
innovators in team-based care.

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Smith CD, Balatbat C, Corbridge S, et al. Implementing Optimal Team-Based Care to Reduce Clinician Burnout. 2018. Discussion paper, National Academy of Medicine. 

This paper describes key features of successful health care teams, reviews existing evidence that links high-functioning teams to increased clinician well-being, and recommends strategies to overcome key environmental and organizational barriers to optimal team-based care in order to promote clinician and patient well-being.

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Levengood TW, Peng Y, Xiong KZ, et al. Team-Based Care to Improve Diabetes Management: A Community Guide Meta-Analysis. Am J Prev Med 2019;57(1):e17-e26. 

This review article assesses 35 RCTs, mostly on T2DM. Compared with controls, team-based care was associated with greater reductions in blood glucose levels and greater improvements in blood pressure and lipid levels. Interventions also increased the proportions of patients who reached target blood glucose, blood pressure, and lipid levels based on ADA guidelines. 

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Fortmann AL, Walker C, Barger K, et al. Care team integration in primary care improves one-year clinical and financial outcomes in diabetes: a case for value-based care. Popul. Health Manag. 2020. 

This article investigates whether a cardiometabolic care team intervention could improve clinical, behavioral, and cost outcomes compared to usual diabetes care in a large primary care group in southern California. Patients and providers reported high satisfaction, there were significant reductions in cost, and patients had greater improvement in glycemic and lip control, diabetes self-management behaviors, and emotional distress. 

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Heart Failure

Creaser JW, DePasquale EC, Vandenbogaart E, et al. Team-Based Care for Outpatients with Heart Failure. Heart Failure Clin 11 (2015) 379-405. 

The authors of this study find that concentrated, team-based outpatient heart failure programs may be able to provide more focused care that could improve the quality of care and patient-centered outcomes, and that implementing team-based care for outpatients with heart failure significantly reduces rehospitalization and cost, and improves functional status and quality of life. 

Vader JM, Rich MW. Team -Based Care for Managing Noncardiac Conditions in Patients with Heart Failure. Heart Failure Clin 11 (2015) 419-429. 

Most HF patients have noncardiac comorbidities, with over 50% of them having 4 or more noncardiac comorbidities. These are associated with adverse outcomes but team-based care strategies improve outcomes. 

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Fendler TJ, Swetz KM, Allen LA. Team-based palliative and end-of-life care for heart failure. Heart Failure Clin 11 (2015): 479-498. 

Team-based palliative care for heart failure implies a multidisciplinary approach, including primary care, cardiology, and palliative care, each represented by various providers. Patients require a heart failure medical home, where various specialties may take a more central role in coordinating patient care at times, sometimes with palliative care consultation, and sometimes transitioning focus to palliative care at the end of life. 

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