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Team-Based Primary Care for the Multimorbid Patient: Matching Complexity With Complexity

Complex, multimorbid patients are individuals within whom multiple chronic diagnoses (usually, more than two)1intersect additional complications—diminished function, cognitive impairment, homelessness, or substance abuse, for example. As many as one third of patients are multimorbid, with correlates of socioeconomic deprivation, increasing health services utilization, and mental health comorbidity.2 The growing scope and scale of care for complex, multimorbid patients has led to corresponding changes in the comprehensiveness required of health systems. Primary care exemplifies this: evolving from the chronic care model, to the medical home, to the integration of behavioral health care, to system-level redesign accommodating multiple chronic diseases and patient-centered priorities like shared decision-making.3, 4, 5 This pattern is a hopeful trajectory toward a multifaceted, responsive primary care system for the complex, multimorbid patient. Despite these new norms, high-functioning teams have been an integral part of excellent care for this patient group.6 Understanding what distinguishes high- versus low-functioning teams and how to optimize the use of teams are critical aspects for primary care health systems.

Teams possess unique characteristics that make them well suited to care for complex, multimorbid patients. Teams themselves are intrinsically complex adaptive systems—that is, the team has properties as a group that exceed the sum of the individual parts.7 Teams have established patterns (reliable outcomes emerging from similar situations) and can self-organize within the bounds of their role, but also have some unpredictability of behavior that depends on interpersonal interactions and daily circumstances.8 This is the core of a team’s benefit for the complex patient: providing care that is individualized, adaptive, and dynamic. Teams encapsulate both the potential best and worst of complexity in health—when operating as a well-functioning unit, the team offers care to the multimorbid patient that is irreplaceable in versatility and depth. When lacking essential structures or suffering breakdowns in relations or cooperation, teams can magnify problems of care already enhanced within multimorbidity.

High-functioning teams have two essential properties, and failures in either can have serious consequences for the complex, multimorbid patient. First, they require a composition with diverse, complementary knowledge and skills matched to the patient’s needs. Complex multimorbid patients may have widely variable needs—from homelessness to dementia—that necessitate a broader range of disciplines in care providers and team members. Secondly, the high-functioning team can operate as a unit only through cooperative and healthy interpersonal relations. An awareness of their roles, shared purpose, and complementary coordination builds otherwise parallel actors to a true team. Teams caring for patients have an additional challenge of including patients as rotating team members while preserving the team dynamics. Optimizing a patient’s participation may require enhanced support, such as explicit coaching, health literacy assessment, or individualized clinical decision aids. Failures in either property, composition or team dynamics, can have large impacts that compound in this patient group who are already at a higher baseline risk for adverse events. Breakdowns in composition jeopardize patient safety and care quality via lapses in care coordination, gaps in needed care, increased workloads for providers and patients, or delivery of unnecessary or unwanted care to the patient. Poor team relations can fracture care on a micro level, also increase waste through redundant effort, and lead to communication errors. Lack of either property can diffuse a team member’s sense of responsibility for tasks—necessary for tackling challenging items such as overtreatment or deprescribing.

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-Linnaea Schuttner, MDa,b, Michael Parchman, MD, MPHc

This article originally appeared in the April 2019 issue of The American Journal of Medicine.

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