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Patient-Centered Teamwork in Care Transitions

The American Journal of Accountable Care®June 2015
Volume 3
Issue 2

Physician-led patient care teams have the potential to impact care transitions to prevent fragmentation of care, and ensure seamless care delivery.


Objectives: Patients are vulnerable to fragmentation of care when transitioning from in-patient settings to ambulatory care offices. Primary care teams can support care transitions by enhancing self-management capability, explaining instructions provided by the hospital staff, addressing lack of patient ability to self-manage chronic disease, and providing resources to contact their primary care physicians. This study explores the link between patient-centered medical home (PCMH) team functioning and the impact of physician leadership on care transitions.

Study Design and Methods: The Maryland Multi-Payor Program includes 52 community-based PCMHs. The Team Perceptions Questionnaire (TPQ) and Care Transitions Survey (CTS) were distributed to 36 parent practices in the program. Of these, 26 practices provided complete data on the surveys.

Results: We observed that positive responses on the TPQ were associated with positive responses to the questions on the treatment and management domain of the CTS (average association effect ranging from 0.24 to 0.35) and in the patient-centered communications and education domain, with average association effects of 0.52 and 0.57, respectively. Physician leadership had a significant impact on team functioning and on care transitions.

Conclusions: PCMHs with high scores on the TPQ have improved care transitions functioning, specifically in the treatment and management of patients, and have a greater likelihood of impacting the overall costs of care. Healthcare reform efforts to develop integrated care transitions teams along with PCMHs and hospitals/long-term care facilities are likely to lead to enhanced teamwork and more seamless transitions for patients that have the potential for cost savings, higher quality of care, and greater satisfaction for both patients and providersBecause outcomes have not necessarily improved as costs of care have risen in the United States, we must revisit primary care delivery. Patient-centered medical homes (PCMHs) are potentially the foundational building blocks for integrated systems of care and the anchors for population health,1 and the adoption of PCMH principles, including team functioning and care management, can lead to enhanced access to care, comprehensive chronic disease management, and patient tracking.2 Patient-centered care delivery has demonstrated early positive impact on the quality of care delivery, modest reduction in costs, and enhanced patient and provider satisfaction.3 However, in the current healthcare system, patients transitioning from in-patient to ambulatory facilities and vice versa are at high risk for fragmentation of care.4

PCMH teamwork is facilitated by leadership, role definition and training of all team members, shared goals, good communication, and measurable outcomes.2,5 PCMHs in the Maryland Multi-Payor Program (MMPP) have primary care teams with goals designed to prevent fragmentation of care for patients who are transitioning from in-patient settings to ambulatory care offices. These goals include increasing self-management capability, fostering comprehension of instructions provided by hospital staff, addressing sparse resources, and ensuring ways to contact their primary care physician.6,7 Patient-centered primary care teams with physician leadership may be well positioned to provide an efficient method to transition patients to and from the ambulatory arena.8 This study explores the link between PCMH team functioning and the impact of physician leadership on care transitions.


The MMPP for PCMHs was established by the Maryland Health Care Commission, pursuant to Maryland Legislative Resolution HB929/SB855 enacted in April 2010.9-11 The MMPP established the Maryland Learning Collaborative (MLC; sometimes known as the Maryland Health Care Innovations Collaborative), housed in the Department of Family and Community Medicine of the University of Maryland School of Medicine, to provide educational and logistic support to transform primary care practices to PCMHs and for implementation of the advanced primary care model.12,13 The 5 commercial insurance carriers participating in the program are Aetna, CareFirst, Cigna, Coventry, and UnitedHealthcare; in addition, public insurers Medicaid and Tricare provide fixed transformation payments toward the advanced primary care model. One-third of fixed transformation payments are dedicated to the development of embedded care management teams that can provide comprehensive, coordinated primary care.14

The MMPP includes 52 practices, representing a mix of rural, semi-rural, urban, and suburban practices. The 52 practices have 36 parent organizations, each with 1 to 4 practice sites. Practices are statewide, are diverse in populations served, and range in size; they include hospital-owned, practitioner-owned, and academic practices, as well as federally qualified health centers, and each practice has transformed into a PCMH recognized by the National Committee for Quality Assurance (NCQA). In total, the practices include 339 practitioners: 277 physicians, 40 nurse practitioners, and 22 physician assistants. The MLC provides PCMH teams with education and teamwork training designed to develop a team process that includes an embedded care manager and is based on the acquisition of practice-specific data to stratify patients by disease using registries or data from the state-designated Health Information Exchange (SDHIE) about utilization of hospitals and emergency departments (EDs).15

There are 52 primary care practice sites with 36 parent practices, caring for 250,000 attributed patients. Payment structures include fixed transformation payments and quality-linked shared savings. All 52 practices are NCQA-recognized at Level 2/3, use electronic health records (EHRs), and utilize their EHR registry function; additionally, 77% are linked to the SDHIE. Most practices are linked to their local hospital discharge teams; they receive daily data from the hospitals and from the SDHIE regarding admissions/transfers/discharges for their patients.16 The MLC provides technical assistance to the PCMHs regarding teamwork, evidence-based medicine adoption, dissemination of patient-centered outcomes research, and quality improvement. It also coordinates support for health information technology through the regional extension center.



Each of the participating practices in the MMPP had received coaching and learning collaborative participation in teamwork; each was also working with an embedded care manager. In all practices that responded, primary care teams were led by physicians. This study’s data sources were the Teamwork Perception Questionnaire (TPQ) and Care Transitions Survey (CTS) (see , available at www.ajmc.com).17,18 The SurveyMonkey tool, which included the Care Transitions Survey and Team Perceptions Questionnaire, were e-mailed to the 36 parent practices and followed by reminder e-mails, phone calls, and mailed notes asking all participants to complete the surveys. In total, 27 practices responded. One person from each practice completed both the TPQ and CTS, and that individual was required to consult with other members of the team. Data was gathered anonymously using SurveyMonkey.

The TPQ consists of 35 Likert scale questions, with 7 in each of these domains: team structure, leadership, situation monitoring, mutual support, and communication. Response choices ranged from (1) strongly disagree to (5) strongly agree. The CTS includes 17 questions—each with 3 response choices: works well, works somewhat, works poorly—in 3 domains: care coordination; treatment and management; and patient-centered communication and education.

In preliminary analysis, we identified the proportions of agree/strongly agree responses to the TPQ and works well responses to the CTS. Using univariate ordinary least squares regression with robust standard errors, we modeled the association between the scores on the CTS and the average score for the TPQ domains. We performed the modeling individually for each of the 17 questions from the CTS as well as for when its questions were grouped in the 3 domains. The average scores for the domains of the TPQ were calculated by assigning a score for the responses to each of the domain component questions (strongly disagree = 1, disagree = 2, neutral = 3, agree = 4, or strongly agree = 5) and taking the average. Similarly, the responses to the CTS were given a numeric score: works poorly = 1, works somewhat = 2, and works well = 3. Multivariate analyses were not undertaken due to the high degree of multicollinearity between the domains of the TPQ and CTS tools.


Table 1

The MMPP had 52 practice locations and included 36 parent practices. A survey was sent to each practice and to each parent company. We received responses from 27 of 36 parent practices (75%); 26 surveys were complete and used in analysis. Each survey returned by a parent practice was completed by a primary care team member—usually a care manager in consultation with other team members. The majority of the questions on the TPQ had a ≥72% response rate of either agree or strongly agree ().

Table 2

The distribution of the responses to the CTS was much more varied (). Questions in the treatment and management domain were marked as works well about 70% of the time. Practices reported high performance on CTS domain areas under medication reconciliation. Responses to questions in the patient-centered communication and education domain received a works well response less than 50% of the time; for the questions in the care coordination domain, this response rate was about 60%.

Table 3

In correlating the survey results from the practices in the TPQ and CTS domain areas, we observed that on average, positive responses on the TPQ were associated with positive responses on the questions from the treatment and management domain of the CTS (average association effect ranging from 0.24 to 0.35; ). Teamwork in a PCMH appeared to have the highest impact on the management of patients in a patient-centered manner. The highest association effect with teamwork was 0.61 in medication reconciliation and communication to the patient/family.

As reported by each responding PCMH parent practices, high scores on the TPQ in teamwork and physician leadership were significantly associated with the CTS domains of care coordination, patient-centered communications, and patient education (Table 3). Specifically, the scores for TPQ had a high association effect (0.46 and 0.45, respectively) with these questions in the care coordination domain: “Knowing when patients have visited the ED, been admitted to the hospital, are going to be discharged and have been discharged” and “Reviewing discharge summaries prior to patient visit.” Similarly, positive responses on the TPQ were associated with positive scores on the CTS questions in the patient-centered communication and education domain: “Eliciting patient goals for post discharge visit” and “Educating patients to recognize and respond appropriately to warning signs/red flags using teach back,” with average association effects of 0.52 and 0.57, respectively.


Advanced models of care require redesign of primary care work flows, reorganization of work responsibilities, and empowering the patient to self-manage health.19 We found that stronger physician leadership responses to the TPQ correlated specifically with the following responses as given in the CTS: stronger team knowledge of patient care transitions; effective inclusion of the patient as a member of the team by eliciting patient goals and providing education on self-management; the efficient provision of a reconciled medication list for the patient to family members, caregivers, and home health nurses; and more direct physician role in ordering tests and assessing and adjusting medications.19 Medication management in particular is a mainstay of reorganized patient care transitions, and it is an area in which patient-centered care with physician-led teams is demonstrating an impact.20

All the PCMH parent practices responding to this survey received real-time data from the SDHIE regarding admissions/discharges and transfers of their patients from EDs and hospitals.21 In addition, primary care teams managed patients on the Encounter Notification Systems list from the SDHIE. The TPQ and CTS responses indicated that there was greatest team awareness on practice knowledge of patient discharge from EDs and hospitals, on eliciting patient goals at discharge, on patient self-management, and on medication reconciliation.

The data from the 26 PCMHs present an interesting dichotomy of the impact of teamwork in a PCMH on care coordination and on patient-centered communication. Although the reorganization of a primary care practice using practice transformation to a PCMH is designed to improve care coordination and patient communication within the PCMH, the impact of such reorganization is not immediately apparent in care transitions. Care transitions focus on patients who are utilizing hospitals and EDs, who are de facto high utilizers of healthcare dollars. Included among these high utilizers are patients with end-stage disease and chronic disease and those with sub-optimal social supports, for whom a PCMH may not be effective as the sole care-transition strategy.22,23 Patients transitioning to and from hospitals and EDs may benefit from wrap-around services supported by the hospitals, the public health infrastructure, and community resource linkages.24 Thus, a PCMH with enhanced communication with hospital discharge teams, and with care coordination supports from local hospitals, has a greater likelihood of success in care transitions. In addition, patients who are repeat ED users demonstrate a greater correlation with social determinants of health, and these patients are most likely to change their behaviors with a concerted and coordinated effort by both the PCMH and the ED.23


While this study is relevant to the field of care transformation and new models of care delivery, it has some limitations. The sample size is small and a single member of the team may have responded on behalf of all team members. As with all self-reported data, there may have been some test-retest bias, and the data were not audited. Further, multivariate analyses were not undertaken due to the high degree of multicollinearity between the domains of the TPQ and CTS tools.


Primary care team structure was demonstrated to have the highest impact of all domains on enhanced care transitions. PCMHs with high scores on the TPQ have improved care transitions functioning and greater likelihood of impacting the overall cost of care. Increased TPQ scores and higher care transitions capability are linked to shared savings.14 The PCMH has the potential to become the ambulatory care coordination center for the healthcare continuum with support from hospitals, long-term care facilities, and community-based resources.25 PCMHs are also positioned to enhance patient self-management, and have the capability to provide ambulatory supports for optimal utilization of the healthcare system.

Healthcare reform efforts, particularly the development of integrated care transitions teams with hospitals, long-term care facilities, and PCMHs, can lead to optimal teamwork and seamless transitions. This scenario would offer the potential for cost savings, higher quality of care, and greater satisfaction for both patients and providers.AUTHORSHIP INFORMATION

Author Affiliations: Family and Community Medicine, University of Maryland School of Medicine (NK), Baltimore, MD; Pharmaceutical Health Services Research, University of Maryland School of Pharmacy (FTS, VVC), Baltimore, MD; Department of Health and Mental Hygiene, Center for Health Information Technology and Innovative Care Delivery (DS), Baltimore, MD; Department of Health and Mental Hygiene, Maryland Health Care Commission (BS), Baltimore, MD.

Source of Funding: The Maryland Health Care Commission (MHCC) established the Maryland Multi-Payor Patient Centered Medical Home Program in 2011 as required by Health-General Article §19-1A-01, et sequentes. The law required MHCC to develop a 3-year pilot, which aims to improve the health and satisfaction of patients and slow the growth of healthcare costs in Maryland, while supporting the satisfaction and financial viability of primary care providers in the State. The 5 largest commercial insurance carriers—CareFirst BlueCross BlueShield, United HealthCare, Aetna, Coventry, and CIGNA—are required under the enabling legislation to participate. TRICARE, a healthcare program for uniformed services members, also participates in the program. Maryland‘s Medicaid agency, the Health Care Financing Administration, supports reimbursement to Medicaid Managed Care Organizations (MCOs) subject to existing budget constraints.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Dr Khanna takes full responsibility for the work as a whole, including study design, access to data, and the decision to submit and publish the manuscript. All authors have made a substantial contribution to the research design, the acquisition, analysis or interpretation of data; have drafted the paper and revised it critically; and have approved the final version of this article.

Authorship Information: Concept and design (NK, BS, DS); acquisition of data (NK, FTS, DS); analysis and interpretation of data (NK, FTS, VVC); drafting of the manuscript (NK, VVC); critical revision of the manuscript for important intellectual content (NK, FTS, DS). Address correspondence to: Fadia T. Shaya, PhD, MPH, University of Maryland School of Pharmacy, 220 Arch St, 12th Fl, Rm 01-204, Baltimore, MD 21201. E-mail: fshaya@rx.umaryland.edu.REFERENCES

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