How does collaboration work in family health teams?

Collaboration in Family Health Teams

Effective collaboration in family health teams operates through interprofessional care models where patients and families function as active team members alongside clinicians, with each professional working at the top of their license to distribute care responsibilities, improve access, and enhance outcomes. 1

Core Structure of Team Collaboration

Team composition is flexible and patient-driven, including physicians, advanced practice nurses, allied health professionals, and crucially, the patient and family in the role they prefer. 2 The team configuration adapts based on:

• Patient complexity and needs at that specific time 2
• Available clinician expertise and scope of practice 2
• Patient preference for their level of involvement 2

Advanced practice registered nurses independently manage stable chronic conditions and routine visits, allowing physicians to focus on diagnostically complex or acutely ill patients. 1 This redistribution of clinical workload enables each team member to practice at their full scope of training and competency. 1

Mechanisms That Drive Effective Collaboration

Patient and Family as Core Team Members

Patients and families must be engaged as active partners, not passive recipients of care. 2 This partnership operates at three distinct levels:

• Direct-care level: Participating in treatment decisions, reviewing visit notes, setting agendas for appointments, and collaborative goal-setting 2
• Organizational level: Serving on advisory councils, participating in quality improvement teams, and providing feedback on care experiences 2
• Policy level: Contributing to resource allocation decisions and development of performance measures 2

Patients who actively participate are more likely to report medication problems and less likely to experience adverse events, reducing downstream complications. 1 Collaborative goal setting increases self-care behaviors and reduces distress in chronic conditions, decreasing urgent visits and hospitalizations. 1

Building a Culture of Caring

The underlying facilitator of interprofessional collaborative practice is a culture of caring—human connections among team members. 3 This culture develops through:

• Building caring relationships among all team members 3
• Developing an ownership mentality where each member takes responsibility for team success 3
• Providing constructive feedback to improve team function 3
• Applying strengths-based practice that leverages each member's expertise 3
• Acting as first and last lines of defense for patient safety 3

Essential Team Characteristics

Cohesive health care teams demonstrate five key characteristics that distinguish true teamwork from simply grouping professionals together:

• Clear goals with measurable outcomes that all team members understand 4
• Clinical and administrative systems that support coordinated care 4
• Division of labor based on scope of practice and expertise 4
• Training of all team members in collaborative practice 4
• Effective communication across disciplines and with patients 4

Evidence-Based Outcomes

Interprofessional team-based care directly reduces patient load burden and improves outcomes by distributing care responsibilities, improving access, reducing hospitalizations, and enhancing practice efficiency. 1 Specific documented benefits include:

• Reduced all-cause mortality and hospital admissions in complex patient populations 1
• Increased access to care and patient satisfaction 2
• Reduced healthcare resource utilization, referrals, and diagnostic tests while lowering overall costs 1
• Reduced lengths of stay and hospital costs 5
• Lowered rates of medical errors and mortality 5
• Improved patient and family cooperation and adherence 5

In Ontario's Family Health Teams, physicians increased total services by 26% per annum and enrolled more patients when practicing in team-based models. 6

Practical Implementation Strategies

Care Coordination Across Transitions

Multidisciplinary interventions bridging hospital admission and discharge to home or transitional care demonstrate effectiveness for managing complex patients. 1 Key strategies include:

• Case management with telephone follow-up and home visits after discharge to reduce readmissions 1
• Specialty clinic follow-up with seamless information sharing back to primary care 1

Shared Decision-Making Tools

Best practices for partnering with patients and families include:

• Using decision aids for preference-sensitive conditions or treatments 2
• Promoting patient self-management of chronic conditions 2
• Setting agendas and goals for care together with patients 2
• Using motivational interviewing to help patients understand their health preferences 2
• Including patients and family members in bedside rounds 2
• Providing transparent access to electronic medical records so patients can review clinical documentation 2

Financial Sustainability

Reimbursement models that incentivize team-based care are essential for sustainable implementation. 1 Effective payment structures include:

• Risk-adjusted per-patient-per-month care coordination fees that support team infrastructure 1
• Bundled payments and accountable care organization models that create incentives for coordinated teamwork 1

Common Pitfalls and How to Avoid Them

Competing organizational priorities and perceived time constraints represent major barriers to implementation. 2 Organizations must recognize that initial time investment in team development yields efficiency gains through reduced errors, hospitalizations, and fragmented care. 1, 5

Clinician training in effectively engaging patients is often inadequate. 2 Teams require specific education in collaborative practice skills, not just clinical expertise. 4

Assuming all patients want the same level of engagement is a critical error. 2 Some patients choose more passive roles due to cultural factors, emotional capacity, or personal preference. 2 The key is asking patients what role they prefer on the care team and respecting that choice. 2

Failing to include patients in system-level improvement initiatives wastes valuable expertise. 2 Patient and family advisors have successfully reduced medication errors by 62% through improved explanations and identified cost-saving solutions in multiple healthcare settings. 2