Components of TBC
- Structured or standardized pre-visit planning/anticipation and planning for upcoming patient visits including method (team meetings/huddles, structured communication, dashboard in the EHR, checklist, appointment notes, etc.)
Workflow or Standards of Care
- Structured or standardized coordination of care with labs, specialists, institutional settings or other care facilities including referral tracking and follow-up, test tracking and follow-up and care transitions.
- Integrate and include the patient/family/caregiver as part of the team.
- Standardized or structural integration community health workers and community pharmacists into the delivery of health services using a team-based care approach (shared values, goals, etc.)
- Other: Warm hand-offs, clinical decision support tools, shared goals, mutual trust, etc.
Communication Processes or Sharing Methods
- Structured communication process or hold regular care-team meetings (such as huddles) for sharing patient information, care needs, concerns of the day and other information that encourages efficient patient care and practice workflow.
- Established bi-directional feedback with health care provider/team and health care extenders.
- Health care team, provider, and patient involved in identifying treatment goals and self-management plans.
Structure, Responsibilities, and Training
- Team-based care structure includes staff that are trained and assigned to manage the patient population.
- Structured tasks and stated staff responsibilities for all staff involved in the care of the patient.
- Staff functioning at the top-of-licensure or role matches skills, abilities, and credentials.
- Standardized method to routinely assess training needs, ensure staff is appropriately trained for their roles and responsibilities, and provide cross training to ensure that patient needs are consistently met.
- Identified clinician lead and a team-based care lead/manager to lead and facilitate implementation.
- Hold scheduled team meetings to address practice or team-based care functioning (outside/in addition to meetings to discuss patient care).
- Staff involvement in quality improvement that includes care team staff in the practice’s performance evaluation and quality improvement activities.