Collaborative Practice Models and Team-Based Care in Oncology

Abstract

Team-based care has been promoted as one essential component necessary for meeting the supply and demand imbalance in the workforce, and as well serving as a crucial element of improving health care delivery.

There is nothing new in the idea that health care should be team based. The age-old model of a mutually agreed on relationship between a patient and a provider establishes a health care team. In the current climate of rapid change in the delivery of health care in the United States, however, this simple model no longer adequately describes team-based care. Technologic advances in the provision of care, increasing regulatory requirements, the challenge of a changing economic climate, mandates of health care reform, and a patient population more fully engaged in decision making regarding their care all contribute to a growing complexity in the provision of health care. All of this is occurring at a time of increasing concern about health care workforce shortages amid increasing demand for health care services in all medical disciplines including oncology.^1–3

Team-based care has been promoted as one essential component necessary for meeting the supply and demand imbalance in the workforce, and as well serving as a crucial element of improving health care delivery.⁴ In oncology, team-based care takes many forms: inpatient care management teams or multidisciplinary disease-oriented care programs, for example. Teams may be large or small and may be located in a variety of practice settings, from the private oncology office to the academic medical center.^5,6,7 It is, therefore, difficult to define team-based care, but the structure of such a definition can be found in the conceptual description of health care delivery by the Institute of Medicine: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”⁴

One practice model that has been promoted as able to improve patient care delivery is the patient-centered medical home (PCMH). In this model, a physician-directed network of care is provided for the individual patient; that care may be provided by other physicians, nonphysician providers, or allied ancillary health services. Although the model was initially promoted for effective management of chronic disease, it has been demonstrated to be an effective model for the delivery of oncology care.⁸ Team-based care is an essential element of the PCMH model, but building successful teams may be difficult in the face of provider shortages. One focus on meeting provider workforce shortages in oncology has been on the role of physician assistants (PAs) and nurse practitioners (NPs).^9–11

The ASCO study of collaborative practice published in Journal of Oncology Practice in 2011 contained critically important data supporting collaborative practice using PAs and NPs in team-based care.¹⁰ Among practices that use PAs and NPs, practice productivity was shown to have increased. Physicians and nonphysician providers had high satisfaction levels. Patients were aware of who was providing the care and were very satisfied with the care received in the collaborative models. The study also reported on reasons physicians did not use PAs or NPs; chief among those reasons were physician reluctance to use nonphysician providers, previous unsatisfactory experience with an NP or PA, and lack of patient volume to support an NP or PA. There is little other data describing barriers to increasing the use of nonphysician providers in oncology practices.

Practices interested in using a collaborative model and considering incorporating PAs and NPs into an existing practice model have a number of issues to consider. PAs and NPs are highly trained and are able to provide services often provided by physicians; however, the education models for PAs and NPs differ, and this may be important in the design of the team and the delineation of team member responsibilities. Licensing and regulation of nonphysician practice occurs at the state level and may be different for PAs and NPs, as may institutional credentialing. An employer or employing institution should have a thorough understanding of the relevant regulatory affairs regarding nonphysician practice. A clear delineation of roles of the providers, designed to maximize the potential for productivity and rendering of patient care services, and a well-defined plan of communication between team members are critical elements in the design of an effective collaborative practice. Practices that use a collaborative model should be familiar with appropriate productivity tracking and reimbursement requirements, not only to accurately reflect the contributions of all team members, but also to appropriately represent the involvement of each provider in the care that is given and billed. Development of effective team-based practice requires that team members have agreed on shared goals, clear roles, mutual trust, and clear communication. In addition, members of a collaborative practice must be fully engaged in a process of ongoing study of their practice and the contributions of the team members to ensure that the practice continues to deliver the highest quality care to its patients in an effective and cost-efficient way.¹²

So where do we go from here? Over the past few years, ASCO has demonstrated its commitment to promoting education regarding collaborative practice through a number of cooperative education programs with the American Academy of Physician Assistants, the Association of Physician Assistants in Oncology, and the Oncology Nursing Society. These cooperative educational programs should continue, with attention to team-based presentation of practice models at appropriate meetings. Additional research on barriers believed by physicians to impede the creation of creating collaborative care models might lead to design of better care models.

Education is another critical component of promoting successful collaborative care models. The 2003 Institute of Medicine report recommends that all health professionals be educated to deliver care in collaborative models.⁴ As Bajorin and Hanley have pointed out, we need to educate oncology professionals at all levels regarding the potential benefits of collaborative practice for our patients and for our practices.¹¹ Equally as important is the need to understand the state of oncology education for nonphysician providers. Postemployment education programs and practice-specific on-the-job training are important elements for practitioners new to oncology, and understanding the existing curricula would allow ASCO and others to develop educational programs targeted specifically for the oncology practitioner. In addition, for the oncology practice or the oncology physician interested in an excellent overview of where we are and what we need to be considering for successful team-based oncology practice, I recommend the ASCO University webinar program and supplemental materials on team-based care in oncology available at http://university.asco.org/team-based-care-oncology-capture.¹³ The webinar and supplemental materials provide an excellent summary of data regarding PA and NP practice in the collaborative model, as well as offering suggestions for the design of a successful team-based collaborative practice model.

Author's Disclosures of Potential Conflicts of Interest

The author(s) indicated no potential conflicts of interest.