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Health care takes a team approach
An increasing amount of facilities are looking at the big picture when it comes to a patient’s condition

Photos by Dan Bishop

January 2015

A team of physicians at Froedtert & the Medical College of Wisconsin
review a medical image together.

As health care becomes increasingly complex, a team-based approach is becoming a widely accepted practice to deliver patient care. Several health care organizations in the Milwaukee area recently shared with M Magazine how they are embracing team-based care to improve quality and promote efficiency in all fields of health care.

Columbia St. Mary’s

A diagnosis of breast cancer can be stressful and overwhelming. But knowing what to expect and having a team of medical professionals to rely on can provide a sense of relief.

That was the impetus for Columbia St. Mary’s Breast Cancer Multi-Disciplinary Clinic, which opened in 2009. "The unknown makes people crazy," says Dr. Alysandra Lal, a surgical oncologist with Columbia St. Mary’s.

But taking a multidisciplinary approach to breast cancer care has helped lessen patients’ anxiety. "Having a team of people gives comfort," says Deb Theine, a nurse navigator with the Breast Cancer Multi-Disciplinary Clinic.

As a nurse navigator, Theine is the first point of contact for patients following their cancer diagnosis. She explains the diagnosis and coordinates appointments with doctors, specialists and support staff like social workers and genetic counselors. "It’s nice for patients not to have to try to navigate the system themselves," says Lal. "It takes a lot off their plate."

But Theine’s role extends far beyond coordinating doctor appointments and surgery schedules. She also helps remove barriers to care, such as managing paperwork, communicating with insurance companies, and helping patients understand their treatment and care options. "It’s a comprehensive approach," she says. "Nothing falls through the cracks."

Multidisciplinary clinics are held every Tuesday at Columbia St. Mary’s Ozaukee campus and every Wednesday at the hospital’s Milwaukee campus. Prior to seeing patients, the clinic team gathers to review patient cases and devise treatment plans.

Next, team members meet individually with each patient so she knows her exact course of treatment. The weekly clinics typically run two to three hours with several patients going through at once.

"In the past, patients had to run around to multiple appointments over several days," says Theine.

Patients who have been diagnosed at other health care systems may also go through Columbia St. Mary’s multidisciplinary clinic for a second opinion.

Although its multidisciplinary approach has made Columbia St. Mary’s a leader in breast cancer care, Lal says it remains a work in progress. Recently, the focus has turned to better supporting patients post-treatment.

"We do this full court press and when treatment is over there’s a bit of a letdown," she says.

Now the clinic is looking into setting up follow-up appointments with a psychologist and other support staff to help patients stay the course on their post-cancer life. "We want to help launch them forward into the next phase of life," explains Lal.

ProHealth Care

Good primary care can improve health outcomes and lower health care costs by enhancing preventive care and improving the management of chronic diseases. That’s the idea behind the patient-centered medical home (PCMH) model — a more personalized health care approach that has been steadily gaining popularity among health care networks nationwide.

"The patient care delivery model is changing," says Dr. Ron Fickel, a physician and chief medical informatics officer for ProHealth Care. "Today, there is more talk about population health management."

Fickel explains that historically, identifying patients’ medical needs has been more episodic, which at times delays people getting the right care at the right time. Now the focus has shifted to making sure all patients who go through ProHealth Care’s primary care network get the same level of care.

To better meet the needs of its patients, ProHealth began implementing the medical home model in its primary care clinics 18 months ago. As part of the approach, the doctor or doctors at each clinic are responsible for leading a team of care managers and health educators to ensure patients — particularly those with chronic illnesses like diabetes and heart disease — receive key tests, take medication as directed, and have access to tools and resources to stay well.

"Our primary care clinic teams are working together to consistently coordinate patient care," says Fickel. "The idea is to build relationships."

Under the medical home model, ProHealth Care’s primary care clinics serve as the hub for coordinating patients’ overall care, from preventative services, to acute care to managing complex illnesses. The approach is designed to help root out serious diseases or health problems before they develop.

"The earlier we’re able to intervene, the much better ability we have to treat patients, which results in better outcomes," explains Fickel.

Improving the continuity of care can also help lower costs over the long term, particularly for those patients with serious health problems who account for much of health care spending.

Resources like electronic patient records are another critical component of the medical home model. The ability to quickly access patient profiles, including test results and health histories, is a vital tool for physicians as they track and manage the health of their patients.

"By getting to know the patient we can design a care pathway that meets their needs," says Fickel. "We’re better able to identify patients who are behind on care."

Froedtert & the Medical College of Wisconsin

Froedtert & the Medical College of Wisconsin has found that a team-based approach can be equally effective for treating chronic health conditions.

Within their individual practices, Dr. William Rilling, an interventional radiologist, and Dr. David Poetker, an otolaryngologist, both encountered patients with Hereditary Hemorrhagic Telangiectasia (HHT), a genetic disorder characterized by malformed blood vessels that lack the structure and durability required to prevent bleeding.

Because the disease varies in symptoms, the two doctors often referred patients to one another — Poetker treating patients with heavy nosebleeds and Rilling treating those with arteriovenous malformations (AVMs) in their lungs.

Eventually, the two doctors agreed that establishing a local HHT program made sense. They enlisted Dr. Robert Krippendorf, an internal medicine specialist with a background in chronic disease management, to serve as the HHT program’s medical director.

"People with HHT have medical needs that need to be expedited as quickly as possible," says Rilling. Today, Froedtert & the MCW’s HHT program is one of just 17 specialized treatment centers nationwide, and the only program of its kind in Wisconsin. In 2012, the International HHT Foundation recognized the program as a Center of Excellence.

With a multidisciplinary team of 15 to 20 specialists, Froedtert & the MCW’s HHT program is able to offer a full spectrum of coordinated care. The team also includes a genetic counselor who can explain the implications of HHT and test family members at risk for the genetic disease.

"Having people in place who can handle the entire continuum of the disease is important because the symptoms are extremely variable," says Rilling. Symptoms can range from frequent nosebleeds to AVMs in the lungs, brain or GI tract, which may result in hemorrhaging or death if left untreated.

Whether patients learn about the HHT program through or are referred by their doctor, their first point of contact is Jule Meddaugh, who serves as the program’s liaison coordinator. Patients who have not yet been diagnosed typically undergo genetic testing to confirm HHT. From there, additional diagnostic tests may be ordered to detect the presence of AVMs.

Following diagnosis, the HHT team helps coordinate care with the patient’s primary care physician. Krippendorf provides patients a full report of their test results, a summary of the HHT team’s findings and a detailed treatment plan.

"HHT can be very frustrating," says Krippendorf. "It makes patients feel good to meet others who know how to pronounce their condition and know what it is."

Wheaton Franciscan

Orthopedic procedures like joint replacement and spinal surgery can be complex and challenging, but for patients with acute medical issues like diabetes and hypertension, there’s often an increased risk for complications.

Seeking better outcomes for its higher risk orthopedic patients, Wheaton Franciscan added orthopedic and spine surgery to the Wisconsin Heart Hospital’s service offerings in 2012.

Before partnering with the Midwest Spine and Orthopedic Hospital, the Wisconsin Heart Hospital had focused exclusively on cardiac and vascular care. But with a shift in health care in recent years away from invasive cardiac procedures in favor of interventional treatments, the hospital had become underutilized.

However, the state-of-the-art facility has proved to be the perfect environment to provide additional support to more medically fragile patients undergoing orthopedic procedures, says Dr. Thomas Perlewitz, an orthopedic surgeon with Wheaton Franciscan.

"It’s suited to those patients with more specialized medical needs," he explains. "The hospital already had a highly trained medical acuity staff, including cardiologists and top-notch nurse practitioners."

Since becoming the Midwest Spine & Orthopedic Hospital/Wisconsin Heart Hospital, the Wauwatosa-based facility has developed an integrated program for orthopedic care, including an evaluation process to help identify high risk patients who might benefit from being treated in a more specialized environment.

Perlewitz says the model of care MSOH/Wisconsin Heart Hospital adopted to treat high risk patients has resulted in improved patient safety, shorter hospital stays, fewer complications and lower health care costs.

"The hospital’s nursing staff is highly qualified to provide critical care," says Perlewitz. "They’re helping patients manage multiple health problems like diabetes, hypertension and blood clots."

Mitigating such health conditions has led to expedited care and clearance for surgery for patients who might not otherwise have been given the go-ahead.

"The specialty hospital environment has allowed us to deliver a more effective continuum of care for this group of patients," says Perlewitz.

He pointed to a recent patient as an example of someone’s quality of life that might have been compromised without additional support from MSOH/Wisconsin Heart Hospital. Suffering from severe spinal stenosis, the woman couldn’t walk more than 100 feet without having to sit down. During the patient’s evaluation, it was revealed she also suffered from peripheral vascular disease, which had restricted blood flow to her legs. Following surgery to repair the women’s spine, Dr. Krisha Kumar, an interventional cardiologist, inserted stents to reopen the blocked arteries in her legs.

"That’s the kind of collaboration we strive for," says Perlewitz. "We want to be engaged at all levels."

Aurora Health Care

Like many health care networks, Aurora Health Care has focused on implementing a team-based approach to improve patient care at the primary care level. Over the next year, all 120 of Aurora Health Care’s primary care clinics will participate in the TeamSTEPPS program — a comprehensive training curriculum developed by the Agency for Healthcare Research and Quality (AHRQ) to improve communication and teamwork skills among health care professionals.

Dr. Andy Anderson, senior vice president of academic affairs, says Aurora adopted the TeamSTEPPS program to empower staff and improve teamwork in an effort to enhance its current patient care model.

"The approach has always been there, we’re just making it come to life by creating an atmosphere that emphasizes communication," says Anderson.

Throughout 2015, doctors, nurses and other staff at Aurora’s primary care clinics will receive training and tools to better facilitate communication. One of those tools is a daily huddle during which the clinic staff comes together as a team to plan for the day ahead and to review what worked or didn’t work during the previous day.

"It’s an open atmosphere that allows people to bring up ideas," says Anderson.

The patients’ voice is also part of the daily huddle, in the form of feedback about their experience during their clinic visit — both positive and negative.

"We’re looking at service delivery through the eyes of our patients so we can develop better quality outcomes," says Anderson.

The TeamSTEPPS approach is designed to help interdisciplinary team members work together to enhance their knowledge and skills for a comprehensive, patient-centered approach. Training focuses on team-building activities that promote leadership and cross-discipline communication.

In the clinics that have received TeamSTEPPS training already, Aurora has reported an improvement in patients’ health care experience, as well as the overall workplace culture.

"Our caregivers feel more like they’re part of a group," says Anderson. He adds that caregivers who feel more fulfilled in their jobs ultimately deliver better patient care.

Along with the TeamSTEPPS program, Aurora is incorporating LEAN principles to encourage a more efficient, streamlined delivery to patient care.

"TeamSTEPPS is the foundation of our primary care redesign," says Anderson. "That approach sets the culture and expectation, but we’re pursuing other initiatives, too."

Children’s Hospital of Wisconsin

More than 5 million infants and children undergo surgery each year, ranging from routine procedures such as tonsillectomies to complex heart-defect repairs. Despite safety advances, though, the death and complication rate is still higher in children than in adults.

To help, a task force commissioned by the American College of Surgeons (ACS) has developed a new classification system that defines the preferred surgical environment for children.

"The intent of these recommendations is to ensure that all infants and children in the United States receive care in a surgical environment matched to their individual medical, emotional and social needs," said Dr. Keith Oldham, surgeon in chief at Children’s Hospital of Wisconsin, who served as the chairman of the national task force that developed the new guidelines.

Studies show better results, including fewer complications and shorter hospital stays, when newborns and children undergo surgery in hospitals with expert resources for pediatric patients. Because of their anatomy and growth stage, children have unique needs, including specialized pediatric anesthesiologists, radiologists and emergency physicians.

Children treated at hospitals without a dedicated pediatric unit often don’t receive optimal care and could face more postoperative risks, according to Oldham. Yet close to half of pediatric surgeries take place in adult-focused general hospitals.

The task force identified three levels of care modeled on the national trauma center designation system the ACS developed in the 1970s.

The highest status, Level I, is for hospitals that perform both complex and routine procedures on newborns and children, including those with the most severe health conditions and birth defects. They must be staffed 24/7 by a wide range of pediatric specialists and have the highest-level neonatal intensive care unit. Level II and III centers must be able to stabilize and transfer critically ill children to a hospital with higher level resources.

Children’s Hospital of Wisconsin is one of 75 health care facilities set to participate in the initial verification process beginning in 2015.


This story ran in the January 2015 issue of: