The triumph of health care will hinge on health professionals reinventing the way in which we work with a patient, with a population, and often overlooked, with each other. We have seen how large conventional multi-disciplinary models are challenged getting to know one patient; conversely, we can admit it is equally challenging for one provider to have all the knowledge needed to provide total care to any one patient or population. 

Additionally, our current systems and processes are structured around physicians and advanced care providers (e.g., nurse practitioners) serving as lead decision-makers with minimal patient inclusion in treatment planning, outcomes tracking and long-term strategy. 

Successful interdisciplinary models of practice must involve a partnership between a team of health professionals with complementary skills and the patient using a participatory, collaborative and coordinated approach. This requires a revamping of how we empower our patients to be a part of our team and how the system can elevate a patient’s leadership in the shared decision-making and self-advocacy it will take to create consistently successful clinical outcomes. 

So, does your team have what it takes to do this? How can you create this culture of necessary change in your medical home? Let’s take a closer look.

Step 1

Distinguish and intentionally create an environment that promotes collaboration, a “working together” mindset. This is uniquely different than co-location, a “working in the same place” mindset, which tends to be the default context for many medical teams.

Step 2

Consider these goals and rank them as they relate to your practice vision.

Patient-centered care
  1. Develop team-based care involving many skills to maximize patient success. Skills may be clinical, behavioral, technical, etc.
  2. Identify potential internal team collaborators: MAs, nurses, health coaches, nutritionists, behaviorists, IT, social media content writers, personal trainers, business development, etc. 
  3. Identify potential external team collaborators: social workers, psychologists, specialists, gyms, chefs, etc.
  4. Identify and implement technology consistent with emerging sociocultural trends (e.g., telemedicine, EMR, etc.)
Evidence-based medicine 
  1. Understand and employ current standards of care that apply to the scope of your unique practice service offering(s)
  2. Determining innovative and progressive uses of emerging evidence, especially if low-risk and high-yield for patients
Population-based care
  1. Optimize practice care through a whole-patient panel perspective
  2. Make sure no patient "falls through the cracks"
Treatment and service performance metrics
  1. Clearly define and track measurable treatment goals 
  2. Change treatments (and/or strategy) until desired outcome is reached
Team care with warm hand-offs
  1. Create communication workflows to coordinate and track in-office care and outside referrals. Get specific here. Start with your most common workflows to increase efficiencies and efficacy.
  2. Systematically and routinely review cases with teams (or team leads), especially for challenging patients or sub-populations of patients of interest
  3. Maintain a structure for regular program oversight and quality improvement

Step 3

Delineate two main leadership teams:

Administrative leadership
  1. Heads up defining and negotiating the scope of the practice’s integrated care, collaborating with the clinical leadership to create the services offered, focuses on operational and financial success 
  2. Negotiates contracts (e.g., insurance, vendor) and creates payment models that support the practice vision
  3. Identifies, builds and supports the collaborative care team, including nurturing the "champions" within the group
  4. Develops and tracks the efficacy and efficiency of clinical and operational workflows
Clinical leadership
  1. Facilitates the identification and adaptation of clinical protocols to the skills of current team members and resources available within the practice
  2. Identifies possible future clinical services of value, including defining resources (e.g., human, technology, and capital) that may need to be implemented
  3. Updates and supports the evidence-based anchor of all clinical workflows
  4. Facilitates the team approach to all patients, and especially the challenging patients, including numerous perspectives of the patient’s case from various team members’ interactions and insights
  5. Develops and implements systems and processes that include regular and active patient participation in care planning


The Bottom Line

So, there you have it—a start to reinventing how you, your patients and fellow team members can reimagine your practice design. Consider using the above points as a first step. Determine if your practice is aligned with what experts suggest is the new, more effective, method of delivering health care. Identify areas of strength in your practice. These may be the practice’s clinical protocols, customer service experience, or dynamic staff members with a desire to expand their contributions. Expand upon what’s already working. Scale what you already do, elevate someone to create another service offering. You can, conversely, identify what’s missing and fill in the gap. This may actually take more time and energy as compared to expanding what’s already working; however, sometimes the gap is big enough that it must be addressed as a priority. 

No matter what you choose to work on, take action. It’s the surest way to improve your outcome. It sounds so simple, and yet, many of us get stuck in the old “paralysis by analysis” loop and wonder why things remain the way they do. Success is the prize when daily small efforts are repeated and dedicated to a higher goal. We can do it. 

  1. C.A. Orchard, V. Curran & S. Kabene (2005) Creating a Culture for Interdisciplinary Collaborative Professional Practice, Medical Education Online, 10:1, DOI: 10.3402/meo.v10i.4387

Shilpa P. Saxena, MD, IFMCP

Dr. Shilpa P. Saxena is a board-certified family practice physician whose passion and purpose come to life through sharing her innovative patient education and practice management solutions in her classic “keep it simple” style. She serves as faculty with the Institute for Functional Medicine and the Andrew Weil Center for Integrative Medicine. She also serves as the Clinical Expert for the CM Vitals Program at Lifestyle Matrix Resource Center. Dr. Saxena is an expert in the group visit medical model, creator of Group Visit Toolkits, and co-author of The Ingredients Matter: India.