EquiCare Toolkit

Overview: Chapter 6 of this National Academies of Sciences’ publication, entitled Designing Interprofessional Teams and Preparing the Future Primary Care Workforce, explores the challenges and innovative solutions for building interprofessional primary care teams that enhance the ability of primary care clinicians’ to deliver comprehensive person- and family-centered care. It examines essential design elements of these teams, emphasizing the roles of extended care members and community-based contributors in delivering high-quality care. Additionally, the chapter addresses workforce diversity and highlights the education and training required to prepare a primary care workforce capable of meeting the evolving needs of individuals, families, and communities.

National Academies of Sciences, Engineering, and Medicine. (2021). Implementing high-quality primary care: Rebuilding the foundation of health care. Washington, DC: The National Academies Press. https://doi.org/10.17226/25983    

Overview: A prominent national advocate for team-based primary care committed to   overcoming challenges in behavioral health integration offers strategies for harnessing technology to improve care delivery and achieving long-term goals. Links to resources provided.   

Purchaser Business Group on Health. (n.d.). Whole-person, team-based care: Transforming delivery with BHI Advisory Group Member Dr. Neftali Serrano. Retrieved December 12, 2024, from https://www.pbgh.org/resource/ransforming-delivery-dr-neftali-serrano

Abstract: Child health disparities in terms of access to high-quality physical and behavioral health services and social needs supports are rampant and pernicious in the United States. These disparities reflect larger societal health inequities (social injustice in health) and lead to preventable population- specific differences in wellness outcomes with marginalized children facing substantial and systematically disproportionate health burdens. Primary care, and specifically the pediatric patient-centered medical home (P-PCMH) model, is a theoretically well-positioned platform to address whole-child health and wellness needs yet, often does so in a way that is inequitable for marginalized populations. This article delineates how the integration of psychologists within the P-PCMH can advance child health equity. This discussion emphasizes roles (i.e., clinician, consultant, trainer, administrator, researcher, and advocate) that psychologists can undertake with explicit intentionality toward promoting equity. These roles consider structural and ecological drivers of inequities and emphasize interprofessional collaboration within and across child- serving systems of care using community-partnered shared decision-making approaches. Owing to the multiple intersecting drivers implicated in health inequities—ecological (e.g., environ- mental and social determinants of health), biological (e.g., chronic illness, intergenerational morbidity), and developmental (e.g., developmental screening, support, and early intervention)— the ecobiodevelopmental model is used as an organizing framework for psychologists’ roles in promoting health equity. This article aims to advance the platform of the P-PCMH to address and promote policy, practice, prevention, and research in child health equity and the important role of psychologists within this model.   

Shahidullah, J. D., Hostutler, C. A., Coker, T. R., Dixson, A. A., Okoroji, C., & Mautone, J. A. (2023). Child health equity and primary care. American Psychologist. 78(2), 93-106. https://doi.org/10.1037/amp0001064 

Overview: This module is part of Advancing Primary Care Innovation in Medicaid Managed Care: A State Toolkit, which was created to help states leverage their managed care contracts and request for proposals to advance innovation in primary care. The two-part toolkit outlines strategies to support states in: (1) defining primary care priorities and advancing core functions; and (2) achieving primary care innovation goals through managed care contractual levers. To view the full toolkit, visit www.chcs.org/primary-care-innovation. This publication emphasizes that innovative team-based care models, which employ staff with diverse expertise and backgrounds, can collaborate to provide high-quality care that meets patients’ needs. 

Crumley, D., Matulis, R., Brykman, K., Lee, B., & Conway, M., Center for Health Care Strategies, Inc. (2019). Enhanced Team-Based Primary Care Approaches: Advancing Primary Care Innovation in Medicaid Managed Care. Retrieved from https://www.chcs.org/media/PCI-Toolkit-Team-Care-Tool_090319.pdf

Abstract:  This article examines the past, present and future of primary care and teamwork. It begins with a definition and description of primary care-its uniqueness, diversity and complexity, including the historical role of teams within primary care. The article then reviews the emergence of innovative primary care teams, including those grounded in new processes such as the Patient-Centered Medical Home and interprofessional teams that include new types of health professionals, particularly psychologists and other integrated behavioral health clinicians. The article describes key factors that support or hinder primary care teamwork, as well as evidence of the impact of these team-based models on patient outcomes, costs, and team members. It also discusses the role of primary care teams within multiteam systems (or ‘teams of teams’), which are organized around the needs of patients and families, and the unique challenges these systems pose to coordinating care. The article concludes with recommendations for advancing teams in primary care, including changes in payment, descriptions of team competencies, models for primary care team training, and research necessary to inform the gaps in scientific knowledge.

Fiscella, K., & McDaniel, S. H. (2018). The complexity, diversity, and science of primary care teams. American Psychologist, 73(4), 451-467. https://doi.org/10.1037/amp0000244 

Abstract – Background: Team-based care is now recognized as an essential feature of high quality primary care, but there is limited empiric evidence to guide practice transformation. The purpose of this paper is to describe advances in the configuration and deployment of practice teams based on in-depth study of 30 primary care practices viewed as innovators in team-based care. Methods: As part of LEAP, a national program of the Robert Wood Johnson Foundation, primary care experts nominated 227 innovative primary care practices. We selected 30 practices for intensive study through review of practice descriptive and performance data. Each practice hosted a 3-day site visit between August, 2012 and September, 2013, where specific advances in team configuration and roles were noted. Advances were identified by site visitors and confirmed at a meeting involving representatives from each of the 30 practices. Results: LEAP practices have expanded the roles of existing staff and added new personnel to provide the person power and skills needed to perform the tasks and functions expected of a patient-centered medical home (PCMH). LEAP practice teams generally include a rich array of staff, especially registered nurses (RNs), behavioral health specialists, and lay health workers. Most LEAP practices organize their staff into core teams, which are built around partnerships between providers and specific Medical Assistants (MAs) and often include registered nurses (RNs) and others such as health coaches or receptionists. MAs, RNs, and other staff are heavily involved in the planning and delivery of preventive and chronic illness care. The care of more complex patients is supported by behavioral health specialists, RN care managers, and pharmacists. Standing orders and protocols enable staff to act independently. Conclusions: The 30 LEAP practices engage health professional and lay staff in patient care to the maximum extent, which enables the practices to meet the expectations of a PCMH and helps free up providers to focus on tasks that only they can perform.

Wagner, E. H., Flinter, M., Hsu, C., Cromp, D., Austin, B. T., Etz, R., Crabtree, B. F., Ladden, M. D. (2017). Effective team-based primary care: Observations from innovative practices. BMC Family Practice, 18(1), Article 13. https://doi.org/10.1186/s12875-017-0590-8