PH Professional Network: Team-Based Care for Professionals in Pulmonary Hypertension

Pulmonary hypertension (PH) has become a chronic disease accompanied by significant physiologic, psychologic, social, spiritual, and financial comorbidities. International guidelines have been developed to guide the evaluation and management of the condition and the Pulmonary Hypertension Association has begun accrediting comprehensive and regional care centers treating patients. An essential component of the guidelines and PH care centers is the multidisciplinary care team. This paper describes a specific model of multidisciplinary care known as team-based care being applied to other complex chronic illnesses that may also prove an efficient and effective model in PH.In 1991, the median survival for patients with pulmonary arterial hypertension (PAH), known at the time as primary PH, was 2.8 years.1 In the nearly 25 years since the introduction of epoprostenol, the PH field has witnessed a rapid expansion of the available therapeutics and our understanding of how to best manage the illness. Today the median survival is more than 7 years from diagnosis: PAH has transformed into a chronic disease. Despite advances in care, PAH remains fatal and is often associated with considerable comorbidity.23Many challenges exist for both patients and providers. The increased availability of evolving pharmacologic options, coupled with recent evidence supporting specific combination drug regimens, has significantly increased the complexity of treating PAH.4 Longer life spans mean that providers must contend with medical comorbidities and intercurrent illnesses. Patients, meanwhile, struggle with the social, emotional, spiritual, and financial ramifications of living with PAH.With the growing complexity of the illness, a multidisciplinary approach has been recognized as an essential component of care. Evidence-based guidelines issued by the American Heart Association, American Thoracic Society, and European Society of Cardiology universally recommend that PAH patients receive care in a multidisciplinary referral center.78 Programs seeking accreditation as a PH care center must include multidisciplinary professionals on their teams.9 In their May 2016 paper discussing the contemporary model for health care delivery and PAH, Chakinala et al emphasize the value of multidisciplinary team-based care in meeting the challenges in contemporary PH care.10 Team-based care (TBC) is a model of care that has demonstrated promise in other fields toward improved outcomes and reduced cost while improving provider satisfaction.1112A number of sources have adopted or adapted an evidence-based, consensus definition of TBC as “…the provision of health services to individuals, families, and/or their communities by at least 2 health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care.”13 The definition is intentionally broad to respect the unique scope, purpose, composition, and methods of health care teams. The Institute of Medicine suggests that team-based health care should adhere to 5 basic principles. Teams should have shared goals, clear roles, mutual trust, effective communication, and measurable processes and outcomes.14Team-based care is more than a group of diverse clinicians working together to care for patients. It is a paradigm shift that moves from a mindset of “I” to a mindset of “we.” Traditional practice models are often centered on a lone physician who makes all patient care decisions. Specific tasks may be delegated, but the physician maintains all the responsibility. TBC distributes not only tasks but also the responsibility for patient care. It empowers every team member to function to the best of their ability and make their highest contribution to patient care.15The patient at the center of every team is the one constant, otherwise the team composition is variable. It can range from a dyad of physician and nurse or medical assistant to a full complement of health care professionals including pharmacists, therapists, social workers, dietitians, and other consultants. Regardless of training and certification, 5 values characterize effective health care team members: honesty, discipline, creativity, humility, and curiosity.14At the outset, goals should be clearly defined for the team and for the care it will provide. Goals should be plainly stated, understood, and accepted by all team members. They can be both patient-specific and generalized to the larger panel or population served by the team. The focus might be clinical outcomes, symptoms, patient satisfaction, quality of life, or cost reduction.11 Each team member should have specific roles with defined functions, responsibilities, and accountabilities that contribute to the team's goals. Team members should work to develop mutual trust, as this will enable them to rely on one another and share in the achievement of goals. Effective communication is essential, and the team should develop and refine communication channels that can be accessed by all team members. Finally, the team should agree on measures to evaluate success and engage in continuous quality improvement.1416Successful teams exhibit distinct traits. A stable team structure allows professionals to build trust and fosters collaboration and team-building. Physical colocation supports a stable team structure, while team training strengthens trust among providers. Adequate staffing is essential to support the model and empower individual professionals to function at the top of their license. Regular team meetings, huddles, and daily interactions foster communication and contribute to team cohesion. All of this requires administrative and often financial support.1516There are no studies directly assessing TBC in PH. In the primary care setting, however, there are data to demonstrate that the team-based model improves markers of quality while decreasing the utilization of acute care, reducing overall health care expenditures.12 Data from heart failure, a chronic disease with similarities to PH, have also shown the model to be effective. In the outpatient setting, Bellam and colleagues report that TBC increased cost-effectiveness, decreased hospitalizations, and provided more resources for patients.17 The impact of TBC might also extend to the inpatient setting. In treating hospitalized patients with heart failure, Larsen and colleagues describe TBC as resulting in better adherence to guideline-based care, shorter lengths of stay, and decreased cost.18Accredited PH care centers already employ multidisciplinary professionals and enacting a team-based model of care may empower and support professionals to make their highest contributions to care. If the benefits for PH centers are similar to those experienced so far in heart failure practices, shifting to TBC has the potential to improve adherence to guidelines, patient outcomes, and staff satisfaction.