The Strategy of Legislative Bill HR 592
February 2015, Vol 3, No 2 - Inside Healthcare
Robert E. Henry

Team-based care is the type of fulfillment HR 592 set out to achieve, not technically increasing pharmacists’ scope of practice, but fulfilling it in a very curious way. Despite the extraordinary diversity in their makeup, all interprofessional provider teams share the quality of overcoming barriers to any provider’s scope of practice. Each team is defined by the patient’s needs.

Team-based care dem­on­strates how pharmacists, physician assistants (PAs), and nurse practitioners (NPs) can treat patients in a wide array of creative care settings.

Proliferation of team-based care would make the passage of HR 592 almost superfluous. Whatever it is or will do to alter the healthcare system, it bears watching and provides lessons in interprovider collaboration and tapping into our knowledge, technology, and diverse skill sets to raise the value of patient care.

Definition, Rationale, Personal Qualities, and Goals

Team-based care is predicated on the assertion that an interprofessional team can address the needs of a patient or group of patients and achieve outcomes and value beyond the capacity of any single provider: physician, pharmacist, or any other provider or healthcare professional. This also entails attaining value-based care—value being the balance of cost, quality, and access.

“The clinician operating in isolation is now seen as undesirable in health care—a lone ranger, a cowboy, an individual who works long and hard to provide the care needed, but whose dependence on solitary resources and perspective may put the patient at risk,” according to a 2012 seminal paper from the Institute of Medicine (IOM).1 This discussion paper was largely embraced the following year by the American College of Physicians position paper.2 It proposed—but wisely refrained from presuming to mandate—standards in definition, and criteria for defining team-based care, the values its participants should possess, and goals.1 The following excerpts from the IOM discussion paper provide essential insights into the vision of team-based care and its objective and subjective attributes1:

  • Proposed Definition
    Team-based health- care is the provision of health services to individuals, families, and/or their communities by at least 2 health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care.
  • Proposed Rationale
    The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective healthcare delivery system.
  • Proposed Personal Qualities Required of Team Members
    Honesty, discipline, creativity, humility, and curiosity.
  • Proposed Principal Goals
    Shared goals, clear roles, mutual trust, effective communication, and measurable processes and outcomes.

Organization of Care Teams

Care teams are organized in highly individ­ualized ways that are tailored to meet the circumstances and needs of patients and caregivers. Its ability to succeed comes from a commitment to the highest ideals of medicine, supported by evidence-based medicine, personalized medicine tech­niques, improved technology, and advances in knowledge of disease states, treatment options, and patient engagement techniques. Each team member is responsible for a particular aspect of the patient’s care. This makes the structure of team-based care heterogeneous and diverse to the extreme.

Moving Toward Personalized Medicine

Reaching into each patient’s individual needs and interests drives the team’s structure as well as the leader elected by its members. A team treating a patient on a multiple drug regimen would logically have a pharmacist directing drug utilization to ensure drug optimization and adherence; such a team might well elect the pharmacist as its team leader. This interprofessional treatment of select patients with special needs is a timely development, providing new efficiencies appropriate not only to new skill sets and technologies required for its execution, but also for changing healthcare needs.

For example, consider the ominous rise of multimorbidity as the baby boom generation approaches and reaches retirement age; this condition exists primarily in patients aged ≥65 years. Multimorbidity is the presence of several chronic and/or acute conditions in a patient. Far more complicated to treat than the comorbid patient, multimorbid patients require care according to guidelines/best practices for each condition. The complexity of ensuring care, counseling, adherence, and engaging patients and caregivers in management and lifestyle modification, if necessary, underscores just 1 situation where team-based care will cut through the Gordian knot challenging successful patient care. A team of providers and support members appropriate to the patient’s needs is more imperative than ever.

Essential Function of Medical Process

If team-based care is growing and essential for the fulfillment of the medical process, it seems axiomatic to increase pharmacists’ scope of practice as well. Seeing pharmacists engaged in these in-depth provider care teams, the impulse arises to borrow President Ronald Reagan’s famous proclamation in reference to the Berlin Wall: “Tear down that wall!” The changes in the political landscape at the time made the Berlin Wall an anachronism that was no longer tenable. Thus, it provides a useful parallel to the imminent fall of limitations on pharmacists’ scope of practice.

Team-based care is emerging in both national and local initiatives; increased pharmacists’ scope of practice is sure to follow, and soon. The team-based care model is still in its infancy, with exploratory models being devised to meet diverse conditions and patient needs. This is a Golden Age of free expression in team-based care, the period before standards are circumscribed. What holds teams together are 2 characteristics: collaboration, and an intense desire to heal by bringing order out of the chaos of multiple factors challenging patient health.

Team-based care transcends the pettiness that has plagued the debate over pharmacists’ scope of practice. Its fresh, sensible vision for collaboration and willingness to experiment with multiple approaches to synthesizing diverse skill sets is a shot in the arm to a healthcare system often stagnated by costs, indifference, divisiveness, and its own bureaucratic regulations.

This brief look at team-based care brings perspective to one of the “modest proposals”—HR 592—seeking to increase pharmacists’ scope of practice. The American Society of Health-System Pharmacists issued a fact sheet about HR 592 which states that although the bill does not technically increase pharmacists’ scope of practice, it was designed to achieve this effect indirectly.3 There is so much potential for pharmacists, PAs, and NPs, now often working together in pharmacy retail clinics, to deliver optimal patient care through interprofessional teamwork before we even approach the ultimate collaboration, team-based care.

Conclusion

Pharmacists’ skills must be used to their full effect. Their day is coming, and team-based care is a vision of how and why interprofessional collaboration is needed and indeed already being implemented. This is changing the debate from whether a patient should be treated by a physician, pharmacist, PA, or NP, to whether they all might be treating certain patients in an intelligent division of labor. The genesis of team-based care shows that this is the future of healthcare. It now remains for those who “get it” to take the initiative and pursue an enlightened, progressive path toward multiprofessional provider care. Value awaits.




References

  1. Mitchell PH, Wynia MK, Golden R, et al; Institute of Medicine. Core principles & values of effective team-based health care. www.iom.edu/Global/Perspectives/2012/~/media/Files/Per spectives-Files/2012/Discussion-Papers/ VSRT-Team-Based-Care-Principles-Values.pdf. Published October 2012. Accessed January 6, 2015.
  2. Doherty RB, Crowley RA; Health and Public Policy Committee of the American College of Physicians. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Intern Med. 2013;159:620-626.
  3. American Society of Health-System Pharmacists. Provider status legislation: H.R. 4190. Frequently asked questions. www.ashp.org/DocLibrary/Advocacy/HR-4190-FAQs.pdf. Accessed January 6, 2015.
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