Dynamic Clinical Care Teams

The Fall Board of Governors Meeting coincided with the publication of ACP’s Position Paper on dynamic clinical care teams. There was lively debate during the creation of this policy statement, but in the end ACP has taken the stance of trying to move forward towards models of care that are most likely to benefit our patients. The paper outlines four general areas – professionalism, licensure and regulation, reimbursement and compensation, research – with definitions and principles that should guide development of clinical care teams. [Link to article].

The Professionalism section defines clinical care teams as the various health professionals “with the training and skills needed to provide high-quality, coordinated care specific to the patient’s needs and circumstances” (emphasis mine). A “culture of trust” is called for to ensure maximum effectiveness, including establishment of shared goals, respect for each member’s particular skills, and quality communication. The paper also reiterates the Institute of Medicine definition of primary care: “The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community”.

The authors also point out that viewing primary care as a single type of care, uniformly provided by a single type of practitioner, is overly simplistic. They outline a spectrum of care that can be viewed in the familiar terms secondary or tertiary, basically from wellness and minor illness to comprehensive care for complex and multiple serious conditions. A guiding principle is that assignment of specific clinical responsibilities within the team should be based on what is in the best interest of the patient. Another principle is the importance of having access to a personal physician trained in the care of the whole person and who has leadership responsibilities for the team, as previously outlined in the Joint Principles of the Patient-Centered Medical Home.

There are three editorials that accompany the piece. Predictably, the American Association of Nurse Practitioners objects to any statement that does not affirm the equality of nurse practitioners as team leaders. The editorial by Thomas Huddle of the University of Alabama at Birmingham School of Medicine points out that there is some ambiguity in the message about team leadership. I agree with his comments on professionalism; the requirement that the professional with the most expertise should be responsible for the approach to care and that it is professionalism that limits practitioners from operating beyond the sphere of their competence. Connecticut internist Anna Reisman also provides important insight; that while the position paper could not be expected to quell the scope of practice debate, continued quarreling over this issue could prevent us from getting where we need to go. Also, she highlights the importance of leadership training to ensure highly functioning teams.Overall, while the paper is likely to draw criticism from practicing physicians as well as from the nurse practitioner community for its nuanced take on team leadership, I applaud ACP for moving the conversation in the right direction and focusing on what is in the best interest of the patient.

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