Value-Based Care: Improving Results in a Decentralized Caregiver Environment 

Value-Based Care: Improving Results in a Decentralized Caregiver Environment 

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Collaboration in health care is essential for better patient outcomes. Collaboration is vital because patient care is fundamentally based on healthcare providers working together, passing the baton for each patient’s care to various contributors to achieve high-quality care while optimizing resources and reducing unnecessary expenses.  A physician may order a prescription over the phone but the pharmacist realizes there is an alternative that may have lower cost or better coverage for the patient.  The nurse injecting the medication also needs to be informed.  And the ensuing delay in that injection interrupts the Physical Therapist’s scheduled visit to the patient. 

In Value-Based Care this is even more challenging as the different caregivers and providers may be employed by a broader and more diverse set of organizations, each organization with its own policies, procedures, and technical infrastructures.  But it still takes a team.

Need Of The Hour

There has been a growing emphasis on training medical students in teamwork over the last decade. Teamwork principles are now being incorporated into various medical school curriculums because a multiplayer environment is instrumental in providing patient-centered, better outcomes. A recent meta-analysis from 1400 acute care teams [Schmutz] found that team performance is 2.8 times more effective in patient care versus organizations lacking teamwork.

Characteristics Of Team Members

According to the Chartered Institute of Personnel and Development (CIPD), the following are the main characteristics of effective team members

  • Common sense of purpose
  • A clear understanding of objectives
  • Resources to achieve objectives
  • Mutual respect among team members
  • Valuing members’ strengths and weaknesses
  • Mutual trust  and willingness to speak openly
  • Range of skills to deal effectively with tasks
  • Range of personal styles for team roles

Three key elements are essential:

  • Effective leadership and governance
  • Supportive team dynamics, and 
  • Clear roles and responsibilities.
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Ongoing Education And Growth

Healthcare teams consist of various disciplines of medicine. They should all be working with a patient-centered approach (common sense of purpose), Meanwhile, gaining knowledge of one another’s disciplines and perspectives. That breadth of awareness can give them a broader perspective of the patient, resulting in better diagnosis and treatment plans.

Breaking Silos

When we are ready to listen and learn from our colleagues, it breaks down the culture of silos. That has many benefits of its own, not just for the work environment but for a better patient outcome as well.  The home-care nurse or even the staff in an assisted living facility realizing a patient is not eating can alert the remainder of the care team to that fact, perhaps avoiding complications.  However, they need to have the means to enable that communication even when the physician may not be routinely looking at the EHR. At this point, can be of real assistance. The HIPAA-Compliant text messaging app has this special feature of one channel for one patient, where all the concerned caregivers can give an update on the patient.

Care Coordination By Data Sharing And Communication

Fostering a culture of smooth and seamless communication and data sharing allows instant access to patient information throughout the entire continuum of care, securely. That fosters respect among colleagues and saves duplication of work.  This is why there is so much emphasis being placed on data sharing between disparate EHRs and EMRs.  HIPAA and privacy more generally are at odds with this sharing of information, contributing to many of the technical challenges in data sharing.

Furthermore, even if we make great strides in the sharing of data and information, we still need more effective ways of securely communicating across disparate organizations, specialties, and participants all with a common purpose of supporting the patient in real-time.  Many caregivers use easily available communication tools like phone and text, but are those both effective and secure versus simply convenient?

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Clear Roles And Responsibilities, Less Errors

Effective teamwork means everyone knows their roles and responsibilities very clearly, which results in improved patient safety, clearly a primary goal of the caregiving process. When roles are clearly defined it also progresses the notion of a rote ‘checklist of activities’ to one where the caregiver attends to the patient with continuous observation and awareness then can continually evolve the treatment plan and inform other members of the team accordingly.

Patient Engagement Plus Job Satisfaction

Modern healthcare considers the patient and their family as essential members of the caregiving team. Whether it is related to what the patient at home is being fed or the emotional support encouraging them to do their exercises and therapy, the patient and their families are necessarily involved throughout the care. Educating them all can be a powerful force-multiplier easing the burden on the licensed healthcare professionals to “do all the work,” lowering costs and improving outcomes.   This can also contribute to providing healthcare professionals with greater job satisfaction, reducing burnout and turnover.  

Quality Care Metrics

Related to the challenges that stem from silo approaches to care referenced above, a team-based approach also measures quality as a team, not as only its independent units within that team.  This raises the importance of communication amongst the team and can generate unique and novel quality care metrics and transparency.

Population Health Management

Population health is itself a value-based care framework.  It is dependent on members of the team recognizing and communicating outliers and signals of information within and across a population. A nurse doing a home visit may detect that patient’s spiking temperature and address it.  But are they prepared and able to communicate that in a way where others on the team but perhaps in a different organization may recognize their patient’s spiking temperature may be a pattern?  In a decentralized caregiver environment managing population health is even more challenging, and dependent on both information sharing and communication. 

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Key Tips

  • Care collaborators must know the importance and effectiveness of cohesive working
  • In a clinical environment goals should be set clearly and precisely, like shift handovers, etc
  • Infrastructure for both data sharing and communication should be considered and intentionally addressed to enable the team to work as one
  • Personal performance, team development, and education activities must be included in setting objectives
  • Care providers ought to undergo training within the supportive framework of a multidisciplinary team.
  • Team members must have the element of trust and respect among themselves to create a beneficent multiplayer environment
  • Constructive criticism is given and received among the members in the most cordial and supportive way.

Success in value-based care is not only measured by the individual caregiver’s or provider’s excellence alone; rather, it is determined by the cultivated collaborative culture of multiple stakeholders working together in a patient-centered way. makes it possible to embrace and enable a collaborative mindset which is crucial for establishing effective team-based healthcare. When every member of the clinical team values teamwork as a core principle and is empowered to work as a team, it enhances outcomes, lowers costs,  and contributes to a more satisfying work environment. This shift in mindset has the power to reshape interactions within clinical settings, potentially leading to a transformation of the healthcare environment.


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