Original Articles

Team-Based Care: A Critical Element of Primary CarePractice Transformation

Debora Goetz Goldberg, PhD, MHA, MBA,1 Tishra Beeson, MPH,1

Anton J. Kuzel, MD, MHPE,2 Linda E. Love, LCSW, MA,3 and Mary C. Carver, FNP-C4

Abstract

The purpose of this study was to gain an in-depth understanding of how primary care practices in the UnitedStates are transforming their practice to deliver patient-centered care. The study used qualitative researchmethods to conduct case studies of small primary care practices in the state of Virginia. The research teamcollected data from practices using in-depth interviews, structured telephone questionnaires, observation, anddocument review. Team-based care stood out as the most critical method used to successfully transformpractices to provide patient-centered care. This article presents 3 team-based care models that were utilized bythe practices in this study. (Population Health Management 2013;16:150–156)

Introduction

The United States health care system is plagued withcountless problems, many of which stem from the frag-

mented and decentralized structure for delivering and payingfor care. Although primary care is seen by many as thefoundation of a well-functioning health care system, it has notreceived a high degree of attention with regard to advances incare delivery mechanisms and reimbursement for services. Infact, the US health care system falls short in many ways whenconsidering Starfield’s definition of primary care as the pa-tient’s first contact with the health system, continuity of carewith the same provider, comprehensive care, and coordina-tion of care across health system components.1 System prob-lems related to primary care include a reimbursement systemthat pays for procedures and episodes of care, and a culturethat has a high regard for high-tech specialized services.Within primary care itself, there are increasing numbers ofpatients with chronic illnesses, declining access to services,dissatisfaction among current practitioners, and decreasingnumbers of new practitioners entering primary care special-ties. In addition to these issues, the Patient Protection andAffordable Care Act of 2010 expands insurance coverage tomillions of uninsured individuals by the year 2014, which isexpected to dramatically increase the demand for primarycare services.2,3

Redesign of the primary care sector is necessary to im-prove access, quality, and patient experience. Efforts to re-

design the delivery and financing system include pilotprojects to test the feasibility of accountable care organiza-tions, which are reimbursed, in part, on patient outcomesand overall savings. Other efforts are aimed at the devel-opment of new models of care delivery at the practice level,with the most prominent being the chronic care model(CCM) and the patient-centered medical home (PCMH)model.4,5 Characteristics of these models include a focus onpopulation health management involving intensive caremanagement for high-risk individuals, coordination of carebetween providers, performance measurement, improvedcare delivery processes, and methods to support patient self-management of care. Health information technology, such aselectronic health records (EHR) and decision-support sys-tems, also are critical components of these models.

Application of the CCM or PCMH model at the practicelevel requires additional activities, beyond those associatedwith the provision of traditional primary care, related to carecoordination and population management. These models aredeeply rooted in the notion that team-based care will resultin the greatest improvement in health outcomes for patients.6

The definition of a team, in this sense, is a group of diverseclinicians who participate in and communicate with eachother regularly about the care of a defined group or panel ofpatients.7

A large body of evidence exists on the role of team-basedcare in improving patient safety, patient-centeredness, andhealth outcomes in primary care settings. Team-based care is

1Department of Health Policy, George Washington University, Washington, District of Columbia.2Department of Family Medicine and 3School of Social Work, Richmond, Virginia.4Carilion Family Medicine, Vinton, Virginia.

POPULATION HEALTH MANAGEMENTVolume 16, Number 3, 2013ª Mary Ann Liebert, Inc.DOI: 10.1089/pop.2012.0059

150

an especially important facilitator of patient safety. Severalstudies found that communication problems between pro-viders accounted for a large majority of adverse outcomesand medical errors, while others have demonstrated thatteam-based quality improvement interventions significantlyreduced the number of preventable adverse drug events.8,9

Furthermore, the use of multidisciplinary teams has beenassociated with reduced medication errors, improved medi-cation adherence, and fewer inpatient hospital days. Addi-tional evidence suggests that multidisciplinary teams canhelp facilitate patient self-management support followingevents that require hospitalization. Several studies have no-ted that, as a result of interventions focused on team-basedcare delivery, both hospital readmission rates and cost ofcare were reduced for chronically ill patients.10–12 Otherstudies confirm the effect of team-based care on health out-comes for patients with chronic disease. Collaboration be-tween nursing, pharmacy, and medical professionals hasresulted in significant reductions in both systolic and diastolicblood pressure.13–17 Similarly, team-based care interventionsfor patients with diabetes have demonstrated achievable im-provements in cholesterol levels, blood-glucose levels, bloodpressure, and body mass index (a measure of obesity).18,19

In addition to improvements in clinical outcomes, team-based care models resulted in increased productivity forproviders of chronically ill patients, allowing health careprofessionals to see more patients, as well as provide morecomprehensive care for patients with complex healthneeds.20 Team-based care models are also effective in im-proving the patient experience in primary care settings.Results from evaluations of existing team-based caremodels suggest high satisfaction rates for both patients andphysicians.21,22

Despite evidence that team-based care can improve qual-ity, patient experience, and provider satisfaction, the adop-tion of team-based care in private practice has been slow.Although many studies have evaluated the outcomes ofteam-based care, there is a dearth of information on thestructure and functioning of successful team-based caremodels, which could help other practices adopt approachessuitable for their needs. This article presents in-depth casestudy research and examines the structure and use of team-based care in 3 primary care practices.

Methods

Study design and sample

The original goals of this study were to examine qualityimprovement efforts and performance of 8 primary carepractices in the state of Virginia using qualitative researchmethods. The study addressed a multitude of transformationefforts, including the use of health information technology(IT), patient engagement, innovative scheduling mecha-nisms, care coordination methods, and functional officespace.

This 2-year project, from 2009 to 2011, included 16 monthsof field work during which more than 90 on-site interviewswith practice clinicians and staff and 36 structured telephoneinterviews were conducted. Physicians, nurses, medical as-sistants, practice administrators, and quality improvementspecialists were interviewed for this project. The study alsoutilized document reviews of policies and performance re-

ports, and observation of staff meetings, team functioning,and individual interactions. Practice sites for study partici-pation were identified based on data obtained from a previ-ous survey of primary care practices in Virginia on theexistence of PCMH model components.23 A purposefulsampling approach was used to select practices for studyparticipation based on a maximum variation of practice lo-cation, ownership, and the existence of the following qualityimprovement activities: team-based care, performance mea-surement, health IT, and use of evidence-based guidelines.The study was approved by the institutional review boards atGeorge Washington University and Virginia CommonwealthUniversity. All study participants signed a consent form.

The goals of the study were to understand what qualityimprovement efforts practices were undertaking, to examinehow these activities were incorporated into their practices,and to identify results of improvement activities. After clo-sely examining the 8 practices over a 2-year period, team-based care was recognized to be the most critical element ofprimary care practice transformation. This realization led toa more careful examination of the successful team-basedmodels used by practices in this study. Successful team-based models were defined as those used by practices thatwere able to demonstrate improved quality of care throughperformance measurement and/or a high level of patientsatisfaction and loyalty. Another key finding from the studywas that clinical leaders have varying preferences and facedifferent environmental conditions and, therefore, need amultitude of options to consider for practice transformation.

Study objectives

This portion of the study highlights 3 primary care prac-tices with team-based care models to describe the details ofeach model, including team composition and functioning.All 3 practice sites were small, with the number of physiciansranging from 1 and 6; utilized an EHR; maintained a team-based care model; and offered programs and services toboost employee satisfaction and morale. All 3 practices ex-celled in patient service and physician and employee satis-faction. Characteristics of the 3 practices described in thisstudy are listed in Table 1.

Data collection

Data collection methods included the use of on-site visitsinvolving recorded interviews, document reviews, and ob-servation of care processes, patient flow, and interactionsbetween individuals, including clinicians, administrativestaff, and patients. Physicians, nurses, medical assistants,practice administrators, and quality improvement staff wereinterviewed; examples of interview questions are displayedin Table 2. Interviews were audiotaped and transcribed fordata analysis. The Virginia Family Medicine Practice Surveyand the National Survey of Physician Organizations alsowere used to collect information from practices on thestructure and functioning of the practice, finances, qualityimprovement efforts, and organizational culture.24,25

Data analysis

Qualitative data analysis involved coding transcriptions ofinterviews using NVivo software (QSR International Pty Ltd,

TEAM-BASED CARE 151

Doncaster, Victoria, Australia) to identify themes within andacross cases as well as unique attributes and experiences. Theresearch team used 3 phases of coding. The first, open cod-ing, involved examining the transcript text and developingcategories or themes of information. This involved a constantcomparative method of identifying instances that representthe category. In the second phase, axial coding, the teamsought to interconnect the categories. The third phase, se-lective coding, involved identifying themes across cases.26

Validity and reproducibility of findings were aided by pri-mary review of transcripts followed by secondary review,triangulation of data from different sources, semi-structuredinterview guides, and maintenance of an audit trail of codedevelopment. Data collection and analysis was conducted by amultidisciplinary research team to draw from different per-

spectives and experiences. The team consisted of individualswith expertise in primary care medicine, nursing, mentalhealth, management, and qualitative research methods. Theanalysis and findings were vetted by an external auditor withextensive experience in qualitative health research.

Results

Across case findings

Three team-based care models emerged from the casestudy research of primary care practices in Virginia. Thesemodels represent various methods to organize a team todeliver primary and preventive care. Each of the team-based care models operates in conjunction with the use ofan EHR and other technology to support data collectionand information retrieval for patient care delivery, trackingpatient care needs, and coordination of care. All team-basedcare models require some level of change in the roles andresponsibilities of individual professionals, as well as ad-ditional training in the use of health IT and expandedclinical functions such as engaging patients in self-man-agement of chronic illnesses. These practices also have well-established relationships with various specialty providersin their communities, which is essential for coordinatingcare for patients.

Organizational culture was shown to be a critical aspect ofa true ‘‘team’’ care model. Team-based practices all exhibitsimilar cultural characteristics including: shared responsi-bility, respect for diversity of skills and knowledge of teammembers, an open environment in which to raise concernsand make suggestions, an emphasis on comprehensive pa-tient care and quality improvement, and team memberwillingness to take on additional roles and responsibilities.Providers and staff also have a high degree of loyalty to thepractice.

Within case findings

Case A—Top of license team model. In this model, teammembers work at the top of their professional licenses to carefor a panel of patients. A patient panel is a group of patients

Table 1. Characteristics of Primary Care Practices Using Team-Based Care

Characteristics Case A Case B Case C

Location Suburban Urban RuralOwnership Health system Health system Independent –

physician ownedPractice age 30 3 25Physicians 1 6 6Nurse practitioners or physician assistants 0 2 0Nurses (RN, BSN, LPN) 3 7 8Medical assistants 2 0 2Average number of patients seen per provider per day 35 301 25Average patient panel size 3,500 2,7002 3,450Electronic health record Yes Yes YesOpen access scheduling3 Yes Yes YesClinical performance measurement Yes Yes NoProductivity and financial measurement Yes Yes Yes

1Physicians see 30 patients per day; nurse practitioners see 22 patients per day.2Average number of active patients seen by providers; inactive patients not counted for this practice.3Same day appointments for urgent and non-urgent appointments.

Table 2. Examples of Interview Questions

What do you see as the most important purpose of yourpractice? What are the most imperative activities you haveto do in order to achieve that purpose?

Can you describe what it is like to work in this practice – thegeneral atmosphere, how people communicate andget along, how they deal with conflict?

Can you tell us how your practice is organized to delivercare?

Can you explain the roles and responsibilities of each teammember?

Can you describe the patient flow in your practice, fromwhen the patient first enters the building to when theyleave after completing their visit?

Describe the process you have for ensuring continuity of carefor patients.

Describe your practice’s relationships (formal or informal)with other specialists in your community.

What do you believe are barriers or areas for improvement toensure continuity of care for your patients?

Explain what changes the practice made in order to improveperformance.

What are the major external and internal factors thatmotivated you to undertake these performanceimprovement efforts?

152 GOLDBERG ET AL.

who get most of their primary care from a given clinician.The team is comprised of a physician, 2 nurses, a patientreferral clerk, and administrative staff. The physician is re-sponsible for the physical exam, data analysis, decisionmaking, and care plan development. Nurses are responsiblefor data gathering and entering most patient care informa-tion into the EHR, as well as care plan implementation andpatient education. A patient referral clerk coordinates refer-rals, including scheduling appointments, and entering con-sult reports into the EHR.

Nurses are given a substantial role in collecting data fromthe patient during the visit, presenting patient problems tothe physician, entering the treatment plan into the EHRduring the physician exam, reviewing the plan with thepatient, and providing patient education after the physicianleaves the exam room. The nurse collects a substantialamount of information from the patient, including the his-tory of present illness, a review of past problems and treat-ments, a targeted systems review, a list of medications andside effects, a social history, and a preventive care update.Nurses are trained to ask disease-specific and symptom-related questions of patients such as questions about chestpain, cough, and abdominal pain. Once the preliminary dataare collected from the patient and entered into the EHRsystem by the nurse, the physician enters the exam room,and then the nurse reports out the information to the phy-sician and the patient. The nurse remains in the exam roomand updates the patient’s electronic chart during the physi-cian visit. Finally, nurses review with the patient any follow-up and disease management issues that were discussed withthe physician, and deliver a written treatment plan to thepatient. At the end of the day the physician reviews, updates,and signs the patient’s chart.

Nursing staff work at the top of their license, which in turnallows the physician to focus on cognitive aspects of diag-noses and treatment and to focus complete attention on thepatient during the exam. This model maximizes the knowl-edge and capability of nursing staff, allows the physician tofocus his or her time on patient care activities, and providesthe patient with an enhanced opportunity to interact withclinical staff.

Although this model required additional nursing staff andtraining for nurses, it allowed the practice to increase itspatient population significantly, generate additional reve-nue, and improve the patient’s experience and quality ofcare. The physician and the nurses reported to the researchteam a considerable increase in job satisfaction under thismodel. Results regarding quality of care, patient satisfaction,and financial outcomes data supporting this model havebeen widely reported in previous publications. For example,the physician went from seeing 22 to 23 patients per day toseeing 35 to 40 patients per day. This, in turn, increased hisgross revenues from less than $400,000 to $580,000 per year.Patient experience surveys were very positive, with 96% ofpatients reporting that they would recommend the practiceto others.27–29 Quality of care also improved, with an in-crease of blood pressure control and low-density lipoproteincholesterol control from approximately 70% in 2002 toalmost 85% in 2007.30

Case B—Care coordinator model. The care coordinatormodel is designed for population management whereby

additional effort is concentrated on managing patients whoare high risk, high complexity, and/or those with high uti-lization of health care services. In this model, the care teamconsists of a provider (physician, nurse practitioner, orphysician assistant), a nurse, a care coordinator, and ad-ministrative staff, all of whom work together to care for apanel of patients. Each care team holds a morning huddle todiscuss patients who have high-risk issues and complexchronic diseases. All team members have access to and shareresponsibility for data entry into the EHR.

The care coordinator, typically a nurse, works for multipleproviders and patient panels. The care coordinator has 2main tasks: coordination of patient transitions in care andpopulation management for high-risk, high-complexity pa-tients. Tasks involved in ensuring effective transitions in careinclude calling patients who have been discharged from thehospital or emergency department to coordinate ongoingcare. Population management involves identifying patientswith poor disease control from a patient registry and en-couraging them to be seen by a provider. The care coordi-nator conducts disease coaching with patients with a specificlevel of poor disease control, which includes providinghealth education and patient self-management support. Thecare coordinator explores barriers to self-management andsetting goals with patients at each coaching session. Thisapproach allows a more concentrated effort to engage high-risk patients in self-management activities. Care coordinatorsreceived additional training in coaching and are now certi-fied as ‘‘chronic care specialists.’’ The practice used a ‘‘Trainthe Trainer’’ style chronic disease coaching education course,which included 2 days of didactics and role-play followed byonline disease education modules.

During the patient visit, a nurse or medical assistant placesthe patient in an exam room and collects and records basicinformation, such as vital signs and the reason for the visit, inthe EHR. Nurses perform higher functions such as admin-istering EKGs and immunizations and identifying patientneeds and deficits in care. The nurse also reviews the patientchart for core preventive care needs such as mammogramsand pneumococcal vaccines. The nurse may perform mini-assessments of the patient; for example, cognitive or mobilityassessment. Outside the office visit, the nurse is responsiblefor answering phone calls from patients, medication refills,arranging prior authorizations, and completing forms.

During the exam, the provider focuses on taking the his-tory, assessing symptoms, conducting the physical, assessingthe need for consultant referrals, interpreting test results,reviewing medication issues, and prescribing new medica-tions. The physician enters data into the EHR on patientprogress notes and laboratory and diagnostic testing orders.How the provider and nurse function as a team depends onhow much the provider ‘‘trains’’ his or her nurse. In the past,the provider dealt with all chronic and acute issues, whichwas difficult to change during transition to the care coordi-nator model.

Refinement of the care coordinator model is an ongoingprocess as the practice encounters new problems and tries tomake the model more efficient and effective. The practicerecently scaled back the number and role of care coordina-tors because of financial difficulty in supporting this modelwith no reimbursement from payers for additional activi-ties associated with population management and care

TEAM-BASED CARE 153

coordination. Implementation of the team-based care coor-dinator model increased the practice’s mammographyscreening rates from 37.2% to 70.46% and their diabeticblood pressure control from 39.2% to 71.96% over a 3-yearperiod (2009–2012). (In November 2011, the practice changedthe diabetes mellitus blood pressure control from 130/80 to140/90 to reflect the current standard of practice.)

Case C—Enhanced traditional model. This multidisci-plinary, high-functioning team model is an enhanced versionof the traditional model whereby the physician performs themajority of patient care during the visit. The team consists ofphysicians, nurses, medical assistants, and front office ad-ministrative staff. Nurses and medical assistants are assignedto a specific physician, unless unusual circumstances arise.All team members are responsible for retrieving and enter-ing data into the EHR related to their assigned roles andresponsibilities.

During a typical patient visit, the patient enters the officeand checks in with the front desk staff and provides up-to-date demographic and health insurance information. Thenurse pulls the patient record information from the EHRand reviews the chart to determine preventive care needs,such as immunizations and medication refills. The nurseescorts the patient to the exam room and checks vital signs,collects basic information on the reason for the visit, andquestions the patient on their general health, symptoms,and other issues. The patient encounter with the nurse andphysician include the history and physical examination.Parts of the history include the chief complaint, history ofpresent illness, review of systems, allergies, medical andsurgical history, family history, lifestyle habits, and medi-cation review. The reason for the visit determines whichcomponents of the history and physical need to be assessedduring the encounter and the level of interaction betweenthe patient and clinical staff. For patients with specificdiseases and those on specific therapeutic regimens such aswarfarin, the nurses maintain a registry of patients for on-going care coordination to ensure completion of necessarytesting and follow-up encounters.

Although this practice engages in fewer activities relatedto population health management than other team-basedcare models, it provides a high level of services to meet pa-tients’ needs. These services include open access for urgentand nonurgent appointments, and available weekend andnight visits. The practice has strong relationships with spe-cialty providers in the region, and administrative staff assistpatients to obtain referral appointments with specialists, in-cluding mental health practitioners. The physicians in thispractice even started a free clinic, separate from the medicalpractice, for patients without health insurance coverage.

At this practice, the team is high functioning because theywork together for the common goal of providing the bestpossible patient care services. Defined roles and responsi-bilities for each team member and effective communicationand trust between individuals are important. The use of EHRtask lists and reminder lists by staff are critical for commu-nication and for effective handoffs between team members.This high-functioning team model has an embedded orga-nizational culture that reflects an emphasis on patient-centered care, reliability, willingness of team members totake on additional responsibilities when needed, and shared

responsibility for patient care—similar to the organizationculture found in the 2 team-based care models presentedearlier. Team members help each other, do what it takes toget the job done to meet patient needs, and work together tobe the best provider in the community. Physicians, nurses,and administrative staff reported high personal satisfactionrates with this model, low patient turnover, as well as patientself-reported satisfaction. Because the practice does not cur-rently collect clinical performance data, quality of care forthis model could not be assessed during the study.

Discussion

Implications

Given the potential addition of 32 million more Americanshaving some form of health insurance in the next severalyears, combined with the aging of the population and thecurrent decline in the primary care workforce, it is essentialto understand practice structures that create greater capacityfor care while improving quality of care. Although the 3models discussed in this study had some variation in rolesand responsibilities, all represent a step away from the‘‘doctor does it all’’ approach. This approach might haveworked when acute care was the focus of primary carephysicians, but is woefully inadequate to attend systemati-cally to preventive services and chronic disease manage-ment, much less population health care.

It is incumbent upon health services researchers to con-tinue to examine what team-based care models are most ef-fective, what makes it possible to create and sustain thesemodels, and how effective models can be disseminated to themajority of primary care practices in the United States. Thisis particularly important for independent practices, whichgenerally have less access to expertise and capital to assistthem to transform their practices into more efficient andeffective models.

The challenges identified by practices in this study pointto the need for new forms of payment for team-based careactivities such as care coordination and population man-agement, as well as ‘‘extension agent’’ services to provideguidance to primary care providers to incorporate newtechnologies and care delivery mechanisms into their prac-tices. The extension agent model has been used for decadesin the United States agricultural sector to transform farmingpractices by employing a local community member to serveas a consultant and coach to local farmers. Primary carecould benefit from a similar model of community-basedhealth extension agents to educate providers about preven-tive medicine, health promotion, chronic disease manage-ment, mental and behavioral health services, evidence-basedtherapies and techniques, quality improvement techniques,and practice transformation. Although included in the Pa-tient Protection and Affordable Care Act of 2010, the primarycare extension agent program has yet to be funded. Localand state policy makers should be working with academicunits, professional societies, and commercial payers to createmechanisms to transform existing primary care practices intomore robust models.

As Chen and Bodenheimer7 pointed out, a critical elementof team-based care is sharing responsibility for the health of apanel of patients, which will allow clinicians to lead a teamrather than individually see one patient after another. The

154 GOLDBERG ET AL.

findings of the current study suggest that team-based carecan help primary care practices manage increasing work-loads. Team-based care models also can help practices meetthe needs of complex and high-risk patients, engage staff inmeaningful work, and improve patient, provider, and em-ployee satisfaction. This study points to the need for theidentification and dissemination of information on varioustypes of team-based care models, which will provide optionsfor clinicians to consider when designing a care model thatbest suits their needs and preferences.

Dissemination of team-based care information to practicesmay best be accomplished by professional associations andother organizations focused on improving quality of care atthe practice level. This study also suggests that practicesinterested in implementing a team-based care model mustfocus on defining new roles and responsibilities, providingopportunities for training in new roles, establishing com-munication mechanisms, changing organizational structureand care processes, and involving employees in the changeprocess.

Author Disclosure Statement

Drs. Goldberg and Kuzel, Ms. Beeson, Ms. Love, and Ms.Carver disclosed no conflicts of interest with respect to theresearch, authorship, and/or publication of this article.

Acknowledgment

This research was funded by the US Department of Healthand Human Services, Agency for Healthcare Research andQuality Grant R01HS018422.

References

1. Starfield B. Is primary care essential? Lancet 1994;344:1129–1133.

2. Elmendorf DE. Letter from the Congressional Budget Officeto the Honorable Nancy Pelosi, Speaker, US House of Re-presentatives on an estimate of the direct spending andrevenue effects of H.R. 4827 Reconciliation Act of 2010 (FinalHealth Care Legislation). Available at: http://www.cbo.gov/doc.cfm?index = 11379. Accessed April 9, 2010.

3. Hofer AN, Abraham JM, Moscovice I. Expansion of cover-age under the Patient Protection and Affordable Care Actand primary care utilization. Millbank Q 2011;89:69–82.

4. Wagner E. Chronic disease management: What will it take toimprove care for chronic illness? Eff Clin Pract 1998;1:2–4.

5. Patient-Centered Primary Care Collaborative (PCPCC). Jointprinciples of the Patient-Centered Medical Home. Availableat: http://www.pcpcc.net/node/14. Accessed November 6,2011.

6. Coleman K, Austin BT, Brach C, Wagner EH. Evidence onthe chronic care model in the new millennium. Health Aff(Millwood) 2009;28:75–85.

7. Chen E, Bodenheimer T. How do we get to the primary careof the future? Adopting a team care approach. Available at:http://www.ihs.gov/california/uploadedfiles/gpra/BP2011_AdoptingACareTeamApproach%28Chen%29.pdf. AccessedNovember 2, 2011.

8. Bates DW, Leape LL, Cullen DJ, et al. Effect of computer-ized physician order entry and a team intervention onprevention of serious medication errors. JAMA 1998;280:1311–1316.

9. Fernald DH, Pace WD, Harris, DM, West DR, Main DS,Westfall JM. Event reporting to a primary care patient safetyreporting system: A report from the ASIPS Collaborative.Ann Fam Med 2004;2:327–332.

10. Rich MW, Beckman V, Wittenberg C, Leven CL, FreedlandKE, Carney RM. Multidisciplinary intervention to preventthe readmissions of elderly patients with congestive heartfailure. N Engl J Med 1995;333:1190–1195.

11. Kaboli PJ, Hoth AB, McCLimon BJ, Schnipper JL. Clinicalpharmacists and inpatient medical care: A systematic re-view. Arch Intern Med 2006;16:955–964.

12. Naylor MD, Brooten DA, Campbell RL, Maislin G,McCauley KM, Schwartz JS. Transitional care of older adultshospitalized with heart failure: A randomized controlledtrial. J Am Geriatr Soc 2004;52:675–684.

13. Bogden PE, Abbott RD, Williamson P, Onopa JK, KoontzLM. Comparing standard care with a physician and phar-macist team approach for uncontrolled hypertension. J GenIntern Med 1998;13:740–745.

14. Borenstein JE, Graber G, Saltiel E, et al. Physician-pharma-cist comanagement of hypertension: A randomized, com-parative trial. Pharmacotherapy 2003;23:209–216.

15. McLean DL, McAlister FA, Johnson JA, et al. A randomizedtrial of the effect of community pharmacist and nurse careon improving blood pressure management in patients withdiabetes mellitus: Study of cardiovascular risk interventionby pharmacists-hypertension (SCRIP-HTN). Arch Intern Med2008;168:2355–2361.

16. New JP, Mason JM, Freemantle N, et al. Specialist nurse-ledintervention to treat and control hypertension and hyper-lipidemia in diabetes (SPLINT): A randomized controlledtrial. Diabetes Care 2003;26:2250–2255.

17. Schneider PJ, Larrimer JN, Visconti JA, Miller WA. Role ef-fectiveness of a pharmacist in the maintenance of patientswith hypertension and congestive heart failure. ContempPharm Pract 1982;5:74–79.

18. Pape GA, Hunt JS, Butler KL, et al. Team-based care ap-proach to cholesterol management in diabetes mellitus: Atwo-year cluster randomized controlled trial. Arch InternMed 2011;171:1480–1486.

19. Scanlon DP, Hollenbeak CS, Beich J, Dyer AM, GabbayRM, Milstein A. Financial and clinical impact of team-based treatment for Medicaid enrollees with diabetes in afederally qualified health center. Diabetes Care 2008;31:2160–2165.

20. Bray P, Roupe M, Young S, Harrell J, Cummings DM,Whetstone LM. Feasibility and effectiveness of system rede-sign for diabetes care management in rural areas: The easternNorth Carolina experience. Diabetes Educ 2005;31:712–718.

21. Kanter M, Martinez O, Lindsay G, Andrews K, Denver C.Proactive office encounter: A systematic approach to pre-ventive and chronic care at every patient encounter. Perm J2001;14:38–43.

22. Rosser WW, Colwill JM, Kasperski J, Wilson L. Progress ofOntario’s family health team model: A patient-centeredmedical home. Ann Fam Med 2011;9:165–171.

23. Goldberg DG, Kuzel AJ. Elements of the patient-centeredmedical home in family practices in Virginia. Ann Fam Med2009;7:301–308.

24. Goldberg DG, Mick SS. Medical home infrastructure: Effectof environment and practice characteristics on adoption inVirginia. Med Care Res Rev 2010;4:431–449.

25. Rittenhouse DR, Casalino LP, Gillies RR, Shortell SM, LauB. Measuring the medical home infrastructure in large

TEAM-BASED CARE 155

medical groups. Health Affairs (Millwood) 2008;27:1246–1258.

26. Cresswell JW. Qualitative Inquiry and Research Design:Choosing Among Five Traditions. 2nd ed. Thousand Oaks, CA:Sage Publications; 2007.

27. Anderson P, Halley MD. A new approach to making yourdoctor-nurse team more productive. Fam Pract Manag 2008;15:35–40.

28. Kuehl N. PCMH Profile. Team-based care leads to financialsuccess. Available at: http://www.aafp.org/online/en/home/publications/news/news-now/pcmh/20090217anderson-q-a.html. Accessed September 22, 2011.

29. Terry K. An effective way to use assistants: Training nursesand MAs to take histories and provide patient educationboosts productivity, income, and quality of care. Availableat: http://www.modernmedicine.com/modernmedicine/

article/articleDetail.jsp?ts = 1320960919648id = 443727. Ac-cessed November 11, 2011.

30. Anderson P, Halley MD. A new approach to making yourdoctor-nurse team more productive. Fam Pract Manag 2008;15:35–40.

Address correspondence to:Dr. Debora Goetz Goldberg

Center for Healthcare QualityDepartment of Health Policy

George Washington University2121 K Street, NW Suite 200

Washington, DC 20037

E-mail: goetzdc@gwu.edu

156 GOLDBERG ET AL.