UCSF

Purpose: The purpose of this multi-sited, interpretive phenomenological study was to explore the team-based care experience for patients with type 2 diabetes and their primary care teams.

Background: Over a decade ago, policy makers began to sound the alarm about an impending workforce crisis in primary care. This crisis endures today, as the supply of primary care providers has not kept up with the high demand from population growth, and an aging population with high rates of chronic disease. Primary care workforce and delivery issues are magnified in the care of patients with chronic conditions, particularly patients with type 2 diabetes. Consequently, patients report frustration with the care they receive, their inability to receive timely access to a primary care provider, and the rising costs that they increasingly share. As primary care workload complexity and demand increase, primary care practices are restructuring to team-based models of care by including interdisciplinary members such as registered nurses, pharmacists, behavioral health specialists, health educators, medical assistants, community health workers, and health coaches on the team. While there is ample and growing evidence of the benefits of team-based care, specifically for patients with type 2 diabetes, little is known about how patients experience team-based care or how it impacts engagement with their care.

Methods: An interpretive phenomenological approach was used to explore this issue within a purposive sample of clinics (n=5) selected to represent different types of primary care and team settings. Forty-one participants from the 5 clinics were recruited, including 17 patients with diabetes, 6 primary care providers (physicians, nurse practitioners, physician assistants), 2 clinic administrators, 4 registered nurses, 2 health educators/wellness coaches, 8 medical assistants and 2 front desk representatives. Four data collection strategies were triangulated: individual semi-structured interviews with clinic patients, team focus groups, targeted observations of team-patient and team interactions; and clinic documents. Interviews were recorded, transcribed and analyzed using an interpretive approach.

Results: The majority of patients experienced team-based care as an enhanced sensation of support: like a family, a net, a support, or a feeling of being surrounded. Team members provided an authentic, nurturing presence for patients to express their suffering, challenges, frustrations and confusions. Patients felt that they entered into a caring community where they felt understood and those caring for them were “there for them.” Team members felt equally supported by a team environment through mutual learning, a shared awareness of patient care responsibilities, and an enhanced sense of joy in practice. Barriers to patients’ engagement with teams include team conflict, poor team communication and organization, inadequate staff training and overly complex or large teams. Several critical practices of high-performing health care teams were revealed: shared commitment (to each other and to their patients), value and care of teammates, mutual learning, trust in each other to perform their roles in the team and strong inter-team communication.

Conclusion: This research provides important insights into the experience of team-based care from within the teams’ and patients’ worlds to highlight what patients value in their health care experience, and how team-based primary care may provide a means to achieving greater patient engagement and satisfaction with their care, while sustaining a more fulfilled and joyful primary care workforce.