Health Teams

Health-focused care requires that primary care physicians evolve beyond "physician-centered care" that is restricted by the dwindling access of the one-on-one physician visit. The family physician of the future can be a leader in the creation of a team of health professionals who provide multiple paths to access care (Figure 2-3) (Grumbach and Bodenheimer, 2004). This may involve group visits, phone contact, and information technology. The goal should be a proactive, collaborative team effort toward meeting patient goals, not just expecting adherence to treatment guidelines (Nutting et al., 2009).

In 2003 the Robert Wood Johnson Foundation supported research to bring behavior change initiatives into primary care to address inactivity, unhealthy eating, smoking, and risky drinking (Cifuentes et al., 2005). Lessons learned from 17 practice-based research networks showed that health behavior change resources are enthusiastically received by practices and patients (Cohen et al., 2005; Woolf et al., 2005), and that practices that use multifaceted team-based interventions are more effective in promoting healthy behaviors than those providing isolated therapy (Goldstein et al., 2004; Prada, 2006; Solberg et al., 2000; Woolf et al., 2005).

When working within teams, it is important to understand the difference among multidisciplinary, interdisciplinary, and transdisciplinary team models (Table 2-3). Traditional multidisciplinary teams are often focused on disease states and are limited to specific organ systems. In multidisci-plinary teams, clinicians work in isolation, with limited

Old model

Acute medical need

Acute medical need




Medical assistant

New model

Chronic disease monitoring \ Prevention need Access needs / Mental health need

New model

Point of care laboratory

Compliance barriers



Health-oriented team

Figure 2-3 Traditional model versus new model of care showing multiple ways to access the health home (medical home).

communication and collaboration. These models tend to focus on body parts or systems in isolation, not recognizing their interdependence Developing a common goal of health facilitation allows professionals to come together to develop interdisciplinary teams that encourage insight toward new ways of problem solving not previously in the group's collective consciousness. When this new insight develops, the interdisciplinary team becomes a transdisciplinary team as its members develop novel ways to create (or promote) health that transcend the "siloed" model of care (Choi and Pak, 2006; Soklaridis et al., 2007).

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