The American College of Physicians’ new blueprint for clinical care teams includes a significant role for advanced practice nurses and other providers, but it keeps physicians firmly in place as team leaders.
For instance, in the case of a patient with advanced diabetes and other chronic conditions, an internist might refer the patient to a nurse practitioner on the care team who has experience educating patients on managing diabetes and other chronic conditions. The nurse practitioner would design a care management program along with the patient and lead those efforts. But the internist would maintain overall clinical responsibility for the patient’s care, according to an example offered in the ACP blueprint.
The ACP published the position paper "Principles Supporting Dynamic Clinical Care Teams" Sept. 17 in Annals of Internal Medicine.
"Internists are particularly well qualified to care for adults with complex illnesses and diagnostic challenges," Dr. Molly Cooke, president of the ACP, said in a statement. "Depending on their specific clinical needs and circumstances, however, patients might appropriately be seen by other members of the clinical care team, with physicians being available for referrals or consultation as needed."
Physicians are best prepared to handle cases where a "diagnostic detective" is needed or for the acute or chronic management of patients with multiple or more complex clinical conditions, the ACP paper noted. However, advanced practice registered nurses and physician assistants can generally provide wellness and preventive care, as well as care of a single, well-defined problem that can be addressed through a standardized treatment algorithm, such as hypertension or hyperlipidemia.
But the ACP also called on all the members of clinical care teams to be open with patients about their skills and training, particularly if they use the title "doctor."
"Because patients view the term ‘doctor’ as being synonymous with ‘physician’ when used in a health care setting, it is incumbent on all health care professionals with a doctoral degree other than MD or DO to clarify that they are not physicians when using the term ‘doctor’ in the patient care setting," the authors of the ACP policy paper noted.
The policy paper, which was developed by the ACP’s Health and Public Policy Committee, notes that most clinical care teams should include physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals. The teams may vary in composition depending on the medical specialty, the clinical setting, and the talents of individual team members.
But to be effective, every team must have a "culture of trust; shared goals; effective communication; and mutual respect for the distinct skills, contributions, and roles of each member," ACP officials wrote.
In the paper, the ACP also calls on medical training programs to spend more time teaching providers how to work as members of a team. And ACP officials also urged policymakers to keep team-based care in mind when making changes to the current health care payment system. The current fee-for-service system does not promote coordinated care, they wrote. But new models such as bundled payments, accountable care organizations, salaried compensation, and risk-adjusted global capitation could help promote team-based care.
"Regulatory and payment policies must be aligned with and support team-based care models rather than creating barriers," Dr. Cooke said.
The paper drew some criticism from the American Association of Nurse Practitioners, which objected to the idea that physicians are the most appropriate providers to lead clinical care teams.
"The AANP believes that team-based care is best thought of as a multidisciplinary, nonhierarchical collaborative centered around a patient’s needs," the group wrote in an accompanying editorial in Annals. "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."
The AANP pointed to Duke University’s department of cardiovascular medicine as one example of advanced practice nurses successfully leading care teams. There, they have moved away from physician-run clinics and instead have nurse practitioners managing patients, with registered nurses providing follow-up care, according to the AANP.