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Editorials |

Championing Truly Collaborative Team-Based Care FREE

Angela Golden, DNP, FNP-C; and Kenneth P. Miller, PhD, FNP-BC
[+] Article and Author Information

From Co-Presidents, American Association of Nurse Practitioners, Austin, Texas.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2120.

Requests for Single Reprints: Angela Golden, DNP, FNP-C, American Association of Nurse Practitioners National Administrative Office, PO Box 12846, Austin, TX 78711; e-mail, admin@aanp.org.

This article was published online first at www.annals.org on 17 September 2013.

Current Author Addresses: Drs. Golden and Miller: American Association of Nurse Practitioners National Administrative Office, PO Box 12846, Austin, TX 78711.


Ann Intern Med. 2013;159(9):642-643. doi:10.7326/0003-4819-159-9-201311050-00714
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As the nation works toward improving health care delivery models, the concept of team-based care has become more pronounced. Thus, defining it is important, as the position paper from the American College of Physicians (ACP) does in this issue (1). That said, the American Association of Nurse Practitioners (AANP) disputes many of the principles that the ACP outlines—first and foremost, the overarching concept that physicians are best-suited to lead health care teams. The AANP believes that team-based care is best thought of as a multidisciplinary, nonhierarchical collaborative centered on a patient's needs. These needs and the patient's preferences should determine which provider leads a health care team. Team leadership should not be defined by a particular professional nor by a regulatory or licensing body.

For some patients, it is necessary and appropriate for a physician to lead the health care team. Other patients, especially those whose needs revolve around such issues as health education and disease management, require the leadership of other providers, such as nurse practitioners (NPs).

Health care systems throughout the country are incorporating NP leaders in health care teams. For example, Duke University Health System's Department of Cardiovascular Medicine has moved away from a model in which physicians ran clinics and delegated care to an approach that has NPs managing patients and registered nurses coordinating follow-up care. The new approach allows all clinicians to work to the top of their education, competency, and licensure (2).

The Duke model reflects the reality that NPs deliver care that is equal in quality to the services of physicians. This is supported by more than 45 years of third-party research—analyses and meta-analyses that are consistent for patients with undifferentiated health problems in various settings, including community-based clinics, primary care clinics, and urban academic medical centers, with NPs providing first-contact, ongoing, and urgent care (35).

The model also reflects the recommendations of a growing number of national think tanks and policy groups. In a landmark 2010 report, the Institute of Medicine advised that NPs, along with physicians and other health care professionals, serve as full partners in the delivery of high-quality health care, as well as the redesign of the nation's health care system, and maintain accountability for their contributions in both arenas (6).

The future of health care in the United States is a model in which physicians, NPs, and other providers all practice at the top of their licenses and competencies and engage in a true exchange of knowledge and responsibility to provide the best possible care for their patients. It is also the way health care currently works in settings nationwide: 17 states and the District of Columbia grant NPs full-practice authority. These professionals take full responsibility for the care of their patients—many who would otherwise not have access to care due to geographic limitations and physician scarcity. However, NPs in full-practice states still collaborate with physicians and other providers. Like all clinicians, NPs coordinate, communicate, and integrate care; seek the advice of specialists on an ongoing basis; and make referrals depending on their patients’ needs.

Such everyday practice embodies truly collaborative team-based care. It is an approach that depends on the judgment of individual clinicians without mandating that one particular provider-type lead.

To achieve truly collaborative team-based care, team leadership cannot be tied to a single profession in the health care team nor be regulated by licensure. These requirements would interfere with the ability of health professions to be regulated on the basis of the preparation and evaluation of individual providers. Regulations should not require team-based care for professional practice. Linked regulatory structures hinder transparency, accountability, flexibility, and the efficient use of clinicians—meeting the needs of lawmakers rather than patients. This position has been affirmed by the Federal Trade Commission and the Antitrust Division of the Department of Justice, which have urged several states to “reject or narrow restrictions that curtail competition among health care providers because they limit access to health care and raise prices” (7).

To keep the best interests of patients in mind while creating the best collaborative care delivery practices, the AANP proposes the following governing principles for team-based care.

First and foremost, the patient is the center of the health care team.

Health care teams consist of patients, as well as their health providers. They do not belong to a single provider, system, or health discipline. They are dynamic, with the needs of the patient directing who can best lead the team at any given point of time.

Characteristics of the health care team include patient-identified and -supported goals, mutual trust among all participants, effective communication, and measurable processes and outcomes in the provision of health care services.

All members of a health care team should practice to the full extent of their education and provide high-quality care for patients at the appropriate time and in various settings to meet the patients’ needs.

The role of NPs on health care teams will vary but may include advocate, clinician, consultant, educator, evaluator, leader, manager, partner, and transformer.

The AANP acknowledges that laws must be modernized to remove barriers to health care systems gaining full benefit from all team members. For example, the AANP believes that the scope of practice laws must be reformed to conform to Advanced Practice Registered Nurse Scope of Nursing Practice within the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (8). The AANP further believes that flexible frameworks are required in health care teams and the health care industry at large to drive innovation and create models to provide the highest-quality care for diverse populations.

Any team's ultimate success requires that all members perform to their full potential. This is especially true in health care given today's increasingly complex landscape, which necessitates the contributions of a multidisciplinary group. It is time that all clinicians recognize this and champion truly collaborative, nonhierarchical team-based care—the best possible care for the patients to whom we all are fiercely dedicated.

References

Doherty RB, Crowley RA, Health and Public Policy Committee of the American College of Physicians. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Intern Med. 2013; 159:620-6.
 
Robert Wood Johnson Foundation.  Putting the Skills, Knowledge, and Experience of APRNs to Full Use. Princeton, NJ: Robert Wood Johnson Foundation; 2013. Accessed at www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/07/putting-the-skills–knowledge–and-experience-of-aprns-to-full-u.html on 9 September 2013.
 
Spitzer WO, Sackett DL, Sibley JC, Roberts RS, Gent M, Kergin DJ, et al. The Burlington randomized trial of the nurse practitioner. N Engl J Med. 1974; 290:251-6.
PubMed
CrossRef
 
Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004; 61:332-51.
PubMed
CrossRef
 
Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005; CD001271.
PubMed
 
Institute of Medicine.  The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Pr; 2010. Accessed at www.iom.edu/Reports/2010/The-future-of-nursing-leading-change-advancing-health.aspx on 9 September 2013.
 
DeSanti SS, Farrell J, Feinstein R.  (Office of Policy Planning, Bureau of Economics, Bureau of Competition, U.S. Federal Trade Commission). Letter to The Honorable Rodney Ellis and The Honorable Royce West, The Senate of the State of Texas. 11 May 2011. Accessed at www.ftc.gov/os/2011/05/V110007texasaprn.pdf on 9 September 2013.
 
National Council of State Boards of Nursing.  Article XVIII. APRN scope of practice. In: NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules. Chicago: National Council of State Boards of Nursing; 2011. Accessed at www.ncsbn.org/Model_Nursing_Practice_Act_March2011.pdf on 9 September 2013.
 

Figures

Tables

References

Doherty RB, Crowley RA, Health and Public Policy Committee of the American College of Physicians. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Intern Med. 2013; 159:620-6.
 
Robert Wood Johnson Foundation.  Putting the Skills, Knowledge, and Experience of APRNs to Full Use. Princeton, NJ: Robert Wood Johnson Foundation; 2013. Accessed at www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/07/putting-the-skills–knowledge–and-experience-of-aprns-to-full-u.html on 9 September 2013.
 
Spitzer WO, Sackett DL, Sibley JC, Roberts RS, Gent M, Kergin DJ, et al. The Burlington randomized trial of the nurse practitioner. N Engl J Med. 1974; 290:251-6.
PubMed
CrossRef
 
Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004; 61:332-51.
PubMed
CrossRef
 
Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005; CD001271.
PubMed
 
Institute of Medicine.  The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Pr; 2010. Accessed at www.iom.edu/Reports/2010/The-future-of-nursing-leading-change-advancing-health.aspx on 9 September 2013.
 
DeSanti SS, Farrell J, Feinstein R.  (Office of Policy Planning, Bureau of Economics, Bureau of Competition, U.S. Federal Trade Commission). Letter to The Honorable Rodney Ellis and The Honorable Royce West, The Senate of the State of Texas. 11 May 2011. Accessed at www.ftc.gov/os/2011/05/V110007texasaprn.pdf on 9 September 2013.
 
National Council of State Boards of Nursing.  Article XVIII. APRN scope of practice. In: NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules. Chicago: National Council of State Boards of Nursing; 2011. Accessed at www.ncsbn.org/Model_Nursing_Practice_Act_March2011.pdf on 9 September 2013.
 

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