Patient-Centered Teamwork in Care Transitions


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 providers.

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