> “In the gradual division of labor, by which civilization has emerged from barbarism, the doctor and nurse have been evolved”
> 
> Sir William Osler (1891)

The delivery of health care by a coordinated team of individuals has always been assumed to be a good thing. Patients reap the benefits of more eyes and ears, the insights of different bodies of knowledge, and a wider range of skills. Thus team care has generally been embraced by most as a criterion for high quality care. Despite its appeal, team care, especially in the primary care setting, remains a source of confusion and some scepticism.1 Which disciplines are essential on the team? What do the team members other than the doctor do to support patient care?

With the ageing of the population and the advances in the treatment of chronic diseases, teamwork in the context of chronic diseases needs to be re-examined. Successful chronic disease interventions usually involve a coordinated multidisciplinary care team.2–5

In this article I consider the implications of these observations for the structure and functioning of patient care teams in primary care. My work is rooted in US health care, and the references and roles described largely reflect that perspective. I performed a Medline search for randomised controlled trials of team care using the MeSH heading “patient care team.”

#### Summary points

Effective chronic illness interventions generally rely on multidisciplinary care teams

Successful teams often include nurses and pharmacists with clinical and behavioural skills

Such teams ensure that critical elements of care that doctors may not have the training or time to do well are competently performed

These elements include population management, protocol based regulation of medication, self management support, and intensive follow up

The participation of medical specialists in consultative and educational roles outside conventional referrals may contribute to …

https://www.bmj.com/content/bmj/320/7234/569.full.pdf

The role of patient care teams in chronic disease management

Is primary care essential

Background: This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care. Methods: One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time. Results: At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients. Conclusion: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

A Multifaceted Intervention to Improve Treatment of Depression in Primary Care

Background For chronically ill patients, readmission to the hospital can be frequent and costly. We studied the effect of an intervention designed to increase access to primary care after discharge from the hospital, with the goals of reducing readmissions and emergency department visits and increasing patients' quality of life and satisfaction with care. Methods In a multicenter randomized, controlled trial at nine Veterans Affairs Medical Centers, we randomly assigned 1396 veterans hospitalized with diabetes, chronic obstructive pulmonary disease, or congestive heart failure to receive either usual care or an intensive primary care intervention. The intervention involved close follow-up by a nurse and a primary care physician, beginning before discharge and continuing for the next six months. Results The patients were severely ill. Half of those with congestive heart failure (504 patients) had disease in New York Heart Association class III or IV; 30 percent of those with diabetes (751 patients) had end...

Does Increased Access to Primary Care Reduce Hospital Readmissions

BACKGROUND Recognizing fundamental fl aws in the fragmented US health care systems and the potential of an

/pdf/the-future-of-family-medicine-a-collaborative-project-of-the-2x0mjiez1y.pdf

The Future of Family Medicine: a collaborative project of the family medicine community.

Section I: Primary Care: Concept and Goals. 1: What is primary care?. 2: A basis for evaluating primary care. Section II: Elements of Primary Care. 3: First contact care and gatekeepers. 4: Longitudinality and managed care. 5: Comprehensiveness and benefit packages. 6: Coordination and the processes of referral. Section III: Primary Care in the United States. 7: Characteristics of practice and practitioners. 8: Organization, financing, and access to services. Section IV: Issues in Primary Care. 9: What type of physicians should provide primary care. 10: Medical records and information systems in primary care. 11: Physician-patient interactionsin primary care. 12: Quality assessment and quality improvement. 13: Community oriented primary care. Section V: Primary Care Systems. 14: Evaluation of primary care programs. 15: Cross-national comparisons of primary care. 16: A research agenda. 17: A policy agenda and epilogue

George G Reader

Papers

Primary Care: Concept, Evaluation, and Policy