1. Care Coordination and Interoperable Health IT Systems
Unit 2: Team-based Approach to Patient Care
Welcome to Care Coordination and Interoperable Health IT Systems, Team-based Approach to Patient Care. This is Lecture c - Evidence-based Clinical Practice.
This unit will explore evidence-based clinical practice guidelines resources .
Lecture c – Evidence-based Clinical Practice
This material (Comp 22 Unit 2) was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit

2. Team-based Approach to Patient Care Learning Objectives
Objective 1: Identify best-practice types of team-based interventions (Lecture a)
Objective 2: Describe key elements for transforming to team-based care (Lecture a)
Objective 3: Plan for transformation to team-based care (Lecture b)
Objective 4: Identify evidence-based clinical practice guidelines resources (Lecture c)
The Objective for this unit, Team-Based Approach to Patient Care, Lecture c, is to:
Identify evidence-based clinical practice guidelines resources.

3. A Change Plan for Team-based Care Transformation
No one, proscriptive approach
General guidance needs to be applied to your context
Plan phases of assessment and reassessment through transformation to a collaborative team-based care model
The following slides provide a general overview from change management and project management perspectives of managing transformation to Team-based Care Coordination.
There is no one, complete, proscriptive approach to this process. This guidance should be considered in the context of your organization’s setting and scale.
A change plan for Team-Based Care Transformation requires planning phases of assessment and reassessment through transformation to a collaborative team-based care model. Phases should include opportunities for gap analysis, milestones measurement and examination from baseline to current milestones progress, monitored and tracked for optimum adaptation during the transformational change process.

4. A Change Plan for Team-based Care Transformation (Cont’d – 1)
Phases should include:
Opportunities for gap analysis
Milestones measurement
Examination from baseline to current milestones progress, monitored and tracked for optimum adaptation during the transformational change process
Refer to Component 18, Unit 10 for more information on Change Management
Phases should include opportunities for gap analysis, milestones measurement and examination from baseline to current milestones progress, monitored and tracked for optimum adaptation during the transformational change process.
Refer to Component 18, Unit 10 for more information on Change Management.

5. A Change Plan: Assessment Phase
Assesses collaborative team leadership and team roles and responsibilities
Establishes a baseline related to:
Team-based care key elements
Standards and criteria defined in the patient-centered medical home team-based care models
In the Assessment phase, start to create an effective measureable plan by assessing the collaborative team leadership and team roles and responsibilities to establish a baseline related to the transformation team-based care key elements, standards and criteria defined in the patient-centered medical home team-based care models.

6. A Change Plan: Assessment Phase (Cont’d – 1)
Assessment allows leadership to aim and prioritize:
Where to most easily begin transformation that will yield the highest results
How to gain early momentum and team experience satisfaction
This allows leadership to target and prioritize where to most easily begin transformation to yield the highest results, gain early momentum, and maximize experience satisfaction. Planned measurement and gap analyses during transformation plan phases strategically reveal when, where and how to analyze and adapt plans to efficiently move towards establishing high-functioning team-based care.

7. A Change Plan: Measurements & Gap Analysis
Planned measurement and gap analyses reveals when, where, and how to analyze and adapt plans to efficiently move towards establishing high-functioning, team-based care
Planned measurement and gap analyses during transformation plan phases strategically reveals when, where and how to analyze and adapt plans to efficiently move towards establishing high-functioning team-based care.

8. Considering Health IT Systems
Systems technology provides:
Opportunities for identification and prioritization of managing clinical conditions
An emphasis on managing population health, wellness promotion, disease prevention, chronic disease management, and patient activation and engagement
Systems technology provides capabilities and opportunities for identification and prioritization of managing clinical conditions with an emphasis on managing population health, wellness promotion, disease prevention, chronic disease management, and patient activation and engagement.

9. Opportunities for Health IT Systems
Properly designed health information technology systems improve opportunities for:
Predictive modeling
Risk assessment
Patient population stratification
Health information technology systems designed to support health condition registries, chronic disease management and population health management, measurement and analytics capabilities can improve opportunities for predictive modeling, risk assessment and patient population stratification.

10. Health IT and High-risk Populations
Analyzing data can identify and prioritize the patient population or provider panel with the highest stratification of most needs and most increasing needs for health care utilization
High-risk or high-acuity patient-population data can be analyzed and used to identify and prioritize the patient population in a given population of patients or a provider panel. This is done in order to measure the highest stratification for the most needs and most increasing needs for health care utilization.

11. Parameters for High-risk Patients
Patients have:
Three or more chronic diseases
Poorly controlled chronic diseases
Demonstrated difficulty with care recommendations and compliance
Three or more hospitalizations and / or emergency department visits in the past year
Identified high health care cost and services utilization according to health plan or payer historical data
Risks associated to social determinants of health (SDOH)
High Risk patients have:
three or more chronic diseases
poorly controlled chronic diseases
demonstrated difficulty with care recommendations and compliance
three or more hospitalizations and /or emergency department visits in the past year
identified high health care cost and services utilization according to health plan or payer historical data
risks associated to social determinants of health (SDOH)

12. Interventions Targeting Chronic Disease
The most common chronic diseases worldwide are:
Heart disease
Stroke
Diabetes
Asthma
Cancer
Chronic obstructive pulmonary disease (COPD)
The most common chronic diseases worldwide are:
Heart disease
Stroke
Diabetes
Asthma
Cancer
Chronic obstructive pulmonary disease (COPD)

13. Interventions Targeting Chronic Disease (Cont’d – 1)
Common, modifiable risk factors that can benefit from team-based intervention:
Unhealthy diet
Physical inactivity
Tobacco use
Refer to Component 21 for more information on Population Health and Health IT Systems
There are many risk factors associated with chronic illness. However, at all ages, the vast majority of chronic disease deaths in men and women can be explained by the following common, modifiable risk factors that can benefit from team-based intervention are:
-Unhealthy diet,
-Physical inactivity
-Tobacco
Although death rates from chronic disease are falling, the prevalence of chronic disease is rising. This is due to changes in population demographics, in particular the ageing of the population, as well as increased exposure to risk factors resulting from social and environmental changes.
Refer to Component 21 for more information on Population Health and Health IT Systems.

14. Utilization of Clinical Care Pathways or Evidence-based Clinical Practice Guidelines
Using evidence-based clinical guidelines, primary care providers can:
Experience degrees of apprehension related to evidence-based guidelines (EBG), creating a “cookbook approach” to clinical care
Discuss, agree upon, and choose their own evidence-based guidelines and measures
Developing a culture of proactive care management depends on providing adequate evidence-based best practice tools into systems. Historically, evidence-based clinical guidelines have been cause for apprehension for primary care providers. Primary Care Physicians fear Evidence-based Guidelines can create a “cookbook approach,” that is overly formulaic and standards-dependent. Primary Care Physicians often prefer an individualized approach that allows for nuance in care.
However in recent years, physicians have become more accepting of evidence-based guidelines (EBGs). They have to ability to discuss, agree upon, and choose their own evidence-based guidelines and measures.

15. Primary Care Physicians (PCPs)
PCPs use evidence-based guidelines:
Embedded in electronic health record systems
Establish standardization of care
Support individualized interaction with patients
Create time for PCPs for individual clinicals
Rest of team attends to the more minimal standards of care
Furthermore, primary care providers can also use EBGs embedded in electronic health record systems to realize the value for establishing standardization of care and continue to support unique individualized interaction and clinical management of patients.
They can find that after implementing structured guidelines for population management they have more time for individual clinical management because their team is attending to the minimal standards of care.

16. Primary Care Physicians (Cont’d – 1)
Develop protocols and guidelines to delegate authority and responsibility to teams
Integrate decision-support mechanisms
Reduce fragmentation, improve safety and quality outcomes
Use data-driven measurement for decision-making and management
PCPs can develop protocols and guidelines to delegate authority and responsibility to teams, integrate decision-support mechanisms, reduce fragmentation, improve safety and quality outcomes and use data-driven measurement for decision making and management.

17. Evidence-based Clinical Practice Guidelines Resources
Institute for Clinical Systems Improvement
Michigan Quality Improvement Consortium
American College of Physicians (ACP)
US Preventive Taskforce
NQF Diabetes
American Diabetes Association (ADA)
American Association of Clinical Endocrinologists (AACE)
Listed on the next few slides are recognized resources for evidence-based guidelines.
Evidence Based Guidelines resources may be embedded within health information technology systems and/or in addition to systems, and support preventive health, chronic diseases or other health conditions as agreed upon by clinicians choosing the guidelines.  
Clinical researchers and/or clinical organizations are responsible for performing research and rigorous development processes to provide resources for the highest quality scientific evidence.
Some of these resources include:
Institute for Clinical Systems Improvement
Michigan Quality Improvement Consortium
American College of Physicians (ACP)
US Preventive Taskforce
NQF Diabetes
American Diabetes Association (ADA)
American Association of Clinical Endocrinologists (AACE)

18. Evidence-based Clinical Practice Guidelines Resources (Cont’d – 1)
Centers for Disease Control and Prevention
Canadian Task Force on Protective
National Heart, Lung and Blood Institute (NHLBI)
American College of Cardiology (ACC)
Agency for Healthcare Research and Quality (AHRQ) U.S. Department of Health and Human Services National Guideline Clearinghouse
Agency for Healthcare Research and Quality (AHRQ) U.S. Department of Health and Human Services Innovations Exchange
Centers for Disease Control and Prevention
Canadian Task Force on Protective
National Heart, Lung and Blood Institute (NHLBI)
American College of Cardiology (ACC)
Agency for Healthcare Research and Quality (AHRQ) U.S. Department of Health and Human Services’ National Guideline Clearinghouse
Agency for Healthcare Research and Quality (AHRQ) U.S. Department of Health and Human Services Innovations Exchange
The references to these resources are listed in the references section at the end of the Lecture slides.
Health IT Workforce Curriculum Version 4.0

19. Properly designed health IT systems hold potential
Unit 2: Team-based Approach to Patient Care Summary – Lecture c – Evidence-based Clinical Practice
A change plan for team-based care transformation requires planning phases of assessment and reassessment
Properly designed health IT systems hold potential
The primary care physicians (PCPs) can utilize evidence-based clinical practice guidelines
There are variety of evidence-based clinical practice guidelines resources available
This concludes Lecture c Evidence-based Clinical Practice of Unit 2: Team-based Approach to Care Coordination.
In summary, this lecture covered:
A Change Plan for Team-Based Care Transformation requires planning phases of assessment and reassessment.
Properly designed Health IT Systems hold potential.
The Primary Care Physicians (PCPs) can utilize evidence-based clinical practice guidelines.
There are a variety of evidence-based clinical practice guideline resources available.
Health IT Workforce Curriculum Version 4.0

20. Unit 2 Summary: Team-based Approach to Patient Care
Team-based care is a proven, preferred model
Foundational elements for successful transformation to team-based care are leadership, communication, and teamwork
There are various recognized resources for evidence-based guidelines
To summarize the unit Team-based Approach to Care Coordination:
Team-based care is a proven, preferred model.
Foundational elements for successful transformation to team-based care are leadership, communication and teamwork.
There are various recognized resources for evidence-based guidelines.

21. Unit 2: Team-based Approach to Patient Care References – Lecture c
508. (n.d.). Retrieved April 12, 2016, from
Canadian Task Force. Retrieved March 08, 2016, from
Centers for Disease Control. (2015, January). Overview of Chronic Disease Indicators. Retrieved March 08, 2016, from
AHRQ Health Care Innovations Exchange. Retrieved March 08, 2016, from
Archived: Diabetes Mellitus (Type 2) in Adults: Screening. (n.d.). Retrieved March 08, 2016, from
Guidelines. (n.d.). Retrieved March 08, 2016, from
Guidelines - American College of Cardiology. (n.d.). Retrieved March 08, 2016, from
Guidelines & More. (n.d.). Retrieved April 12, 2016, from
Handelsman, Y., Bloomgarden, Z. T., & Grunberger, G. (2015). American College of Endocrinology—clinical practice guidelines for developing a diabetes mellitus comprehensive care plan—2015. Endocr Pract, 21(Suppl 1), 1-87
No audio.

22. Unit 2: Team-based Approach to Patient Care References – Lecture c (Cont’d – 1)
MQIC Guidelines. (n.d.). Retrieved March 08, 2016, from
NGC is a public resource for evidence-based clinical practice guidelines. (n.d.). Retrieved March 08, 2016, from
Standards of Care. (n.d.). Retrieved March 08, 2016, from
Systematic Evidence Reviews and Clinical Practice Guidelines. (n.d.). Retrieved March 08, 2016, from
No audio.
Health IT Workforce Curriculum Version 4.0

23. Unit 2: Team-based Approach to Care Coordination Lecture c – Evidence-based Clinical Practice
This material was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006.
No audio.
Health IT Workforce Curriculum Version 4.0