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Team-Based Healthcare: The Status Quo is Not Good Enough
Primary care works best as multidisciplinary, team-based healthcare. Behavioral clinicians are critical team players. While superior to solo care, team-based care today is marred by fundamental deficiencies. Beyond specific shortcomings, there is an unfortunate tendency to simplify teambuilding. A fallacy persists that assembling clinicians who are collegial will ensure a cohesive team.
A group of people working together with different skills is not a team. There needs to be some common orientation binding people together into a team. While teams should attract and energize members, more than team spirit is needed. Teams need clear roles and lines of communication to function well.
The conundrum is that primary care needs greater investment in teams immediately. However, we are ill-advised to fund a flawed status quo. We need to begin considering alternative ideas that might produce higher functioning teams. The universal behavior model (UBM) is one alternative to consider.
The Current Dilemma
Thought leaders are rightly calling for the US to make major investments in primary care, arguing that our poorly funded primary care system needs revenue for more players of every type. An estimate of this funding shortfall, based on a comparison with 22 Organisation for Economic Co-operation and Development (OECD) countries with better health outcomes, suggests needing $96 billion annually to match these advanced countries.
Primary care teams are not new, nor are reports of disenchanted team members. The few therapists on any given team often find their multifaceted and broad roles quite stressful. Primary care physicians (PCPs) often find that teams impact their daily work little, and so enthusiasm fades.
UBM suggests a simpler tack for therapists—focus on people’s thoughts, feelings, and actions, and listen like a therapist. Try to avoid the trap ensnaring PCPs. Many feel pressured to always have a plan of action and fear negative judgment for lacking one. Prescribing can be a statement that patient complaints are heard. PCPs need a new model for interacting and communicating with patients.
The physician exodus from primary care is a familiar story. Inadequate pay and administrative burden are key factors, but frustration with the work itself is also real. Chronic conditions account for 75% of total costs, with roughly 75% of those costs driven by behavioral issues. Most PCPs never signed up to be behavior change experts. Given the few patients seen for therapy, little change occurs practicewide.
Recruiting for New Teams
UBM imagines cohesive primary care teams with players using new skills that combine the psychosocial and medical models. Every clinician considers both in this comprehensive care approach. Behavioral care is as fundamental as medical care. They are inseparable. Work can overlap, but team roles are distinct. Each role breaks with tradition in some way. Consider this brief synopsis of team positions.
Psychiatrists. While most psychiatrists practice today in relative isolation, they are needed in this new primary care setting as physicians trained in the biopsychosocial model. Primary care should be grounded in the inseparability of its dimensions. Psychiatrists are much needed physician leaders with broad capabilities. The status quo has them perfecting use of psychotropics, a mere fraction of what they can offer.
Psychotherapists. Psychotherapy has been proven remarkably efficacious, based more on the therapist than the clinical techniques used. These new teams need therapists using their skills in new ways. They must work with new time constraints (visits under 20 minutes) and yet find ways to engage people in changing thoughts, feelings, and behavior. They should focus on being therapeutic with patients, not on consulting to PCPs.
Primary Care Physicians. The PCP follows a mnemonic in the new model, Behavior in All Diagnoses, or BiAD. It means that behavior (broadly speaking) can impact any diagnosis or condition for better or worse, and care is likewise impacted. PCPs personally address behavior change to the extent comfortable, but it is seen as a primary focus for the team. Medical and behavioral care are equally critical and interconnected.
Executives. The most important person in an orchestra, the conductor, does not play a single note. So too, executives have no specific care responsibilities but are indispensable in creating team cohesion. Success for this model hinges on having executives carry a unifying vision of the biopsychosocial orientation to stakeholders internally and externally. Changing the status quo is never welcome initially.
Moving Beyond Siloed Communication
The current view of integrated care is flawed. Building multi-disciplinary teams and encouraging collaboration is not good enough. Communicating across disciplinary silos leaves the silos intact. Many are consultants, not fully engaged team members sharing responsibility for the health of a population.
Teams do not embody a biopsychosocial orientation simply because they are multidisciplinary. It requires elevating behavior change and psychosocial solutions in importance. Behavior change is the missing ingredient not only in chronic care, but also in prevention and early intervention.
UBM facilitates cohesiveness around a biopsychosocial view of clinical care. Let us start building better teams and then focus on securing the billions needed to strengthen primary care.
Ed Jones, PhD, is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health. Norm Ryan, MD, is a primary care physician who has held senior medical executive roles with Alere Health, UnitedHealthcare, and Humana.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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