It takes a patient-centered village to improve cardiac health

‘ACOs with a central focus on advanced primary care teams experience positive results in terms of cost, quality and utilization.’* 

As a broad community of U.S. healthcare providers, we continue to better understand the critical importance of shared decision-making in a team environment to deliver optimum patient-centered care. While there continue to be challenges in its implementation, we know the benefits of team-based care:

  • Leverages diverse skill set and knowledge of entire care team
  • Reduces delays in care and avoidable errors by using established lines of communication and processes
  • Cost-effective due to unnecessary duplication of services across providers
  • Saves both the patient and your practice some serious money in a value-based care (VBC) reimbursement environment.

We’re rapidly moving away from fee-for-service models, and advanced accountable care organizations (AACO) — such as those based on the patient-centered medical home (PCMH), Comprehensive Primary Care Plus (CPC+) and other pay-for-performance (P4P) models — are already waist-deep in guidelines that incentivize them to make changes to their delivery structure and processes to provide care that meets or exceeds quality and cost benchmarks.

We also know that the U.S. has a growing shortage of physicians that’s reaching crisis proportions. The shortage is estimated at between 42,600 and 121,300 physicians by 2030, especially in primary care, the specialty that drives patient-centered care in most models. With a burgeoning senior population of baby boomers who are retiring and living longer, a physician shortage couldn’t come at a worse time.

But while physicians remain at the center of directing care, many other levels of care professionals are being recognized and utilized for their roles as part of the “village” that delivers both evidence-based, best-practice prevention and treatment.

Team-based care in cardiovascular patients

In my last blog on aspirin use, I highlighted some of the recommendations within the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. This recently released report discusses the joint American College of Cardiology/American Heart Association Task Force’s guideline for preventing and treating cardiovascular disease, and the impact of patients’ lifestyle choices in their conditions and care. This nearly 100-page report is an invaluable tool that’s based on the latest body and quality (level) of evidence, (LOE) and the class of risk (COR) for atherosclerotic cardiovascular disease (ASCVD).

Page 4 of the report provides a helpful “top 10” list of prevention of cardiovascular disease. Interestingly but not I hope surprisingly, #1 talks about promoting a healthy lifestyle for patients of all ages. And at #2, — well before guidelines for the use of aspirin, statins or diabetes care — is a reminder that “A team-based care approach is an effective strategy for the prevention of cardiovascular disease, including that clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.”

That’s what we do at RxLive on the medication management side of healthcare, and why we were founded. So there are no huge surprises in the report that I find or disagree with. But promoting healthy lifestyles and utilizing a team approach being at the top of this list really drives home this fundamental point — to deliver effective and cost-efficient care in a value-based care (VBC) world, we must all work together, seamlessly and with established and sustainable means and standards for timely communication.

We all know that the most avoidable errors, costs and care delays tend to come in the handoffs — or lack thereof — between physicians and their teams with other practices, hospitals, ambulatory cares and other care providers due to poor communication. It’s even true from shift to shift in hospitals. That’s why effective means and protocols for communications, an understanding of evolving roles, and coordination not only within a provider’s team but across providers is so essential to success.

Another report Creating Patient-centered Team-based Primary Care prepared for the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Dept. of Health & Human Services — acknowledges the importance and challenges in collaboration and communication across the healthcare environment. They cite that “Well-implemented team-based care has the potential to improve the comprehensiveness, coordination, efficiency, effectiveness and value of care, as well as the satisfaction of patients and providers.”

Further, the team of authors note the intrinsic value that various health providers — such as PAs, NPs, clinical pharmacists, physical therapists and others — bring to the table: ”Fundamental to (a patient-centered) approach is the belief that, when practices draw on the expertise of a variety of provider team members, patients are more likely to get the care they need. A larger provider team might also support quality improvement. With effective intra-team communication and problem-solving, practices can engage in data-driven, continuous quality improvement.”

Well stated. The report and its extensive citations make for an excellent read. (The article is free to read online or to download as a PDF.)

Case studies showing team-based results

Unfortunately, many healthcare organizations have been founded — and still operate — under a hierarchical structure that inhibits communication, stifles full participation, and undermines teamwork. But in our changing environment, the situation is quickly changing all levels…from the smallest, most loosely aligned providers to the largest health systems and plans. Interoperability finally gaining ground across health IT systems such as electronic health records is having a positive impact as well, though much work remains, as evidenced by HHS’s new proposed rules to improve interoperability to “building a healthcare system that pays for value rather than procedures.”


An independent study released in the New England Journal of Medicine (NEJM) shows that the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC) has generally improved the quality of patient care and lowered spending growth in the first four years since it was launched.

The study, conducted by researchers at Harvard Medical School and funded by the Commonwealth Fund and the National Institute on Aging, compared BCBSMA members with a primary care physician in an AQC contract with a control group of commercially insured individuals across eight northeastern states.

Researchers concluded that spending growth among patients in the AQC was nearly 10% lower than the control group. Quality of care was significantly higher than national averages. The findings relative to the control group are notable because they account for more general trends locally and nationally — showing that the AQC attained greater value than what was occurring in the general environment.

“The AQC has been transformative,” said Leslie Sebba, MD, medical director of the Northeast Physician Hospital Organization. “It’s allowed us to innovate because it enables us much more to think like a system rather than as an individual doctor or a small individual practice. Most of the practices in a community like ours are two to five physicians at the most; through AQC, we’re able to introduce programs broadly across all the practices. The AQC allows us to do things more efficiently and gives us the resources to implement programs that would be very difficult for small practices to do.”

WHO and team approach to better care

In a 2018 World Health Organization report on cardiovascular disease management comes out strongly in support of a collaborative team-based approach to achieving better outcomes. I’m personally pleased that in many places including WHO case studies, the report specifically includes pharmacists as an integral part of that coordinated care team, performing medication evaluation and management services such as we provide at RxLive. Four case studies from around the world are included, all applicable to U.S. health organizations moving towards or enhancing their team-based care approach.

Team-based PCMH at VHA

A study specifically focusing on using the team-based approach to improving patient outcomes and satisfaction by PCPs at the Veterans Health Administration determined the strong link between better intrateam communication and improved patient-provider communication with high patient satisfaction (81%). That was compared with poor intrateam communication and poor patient-provider communication (22%).

The study’s authors concluded that “PCMH environments with better communication among team members are likely to experience better patient-provider communication and high patient satisfaction. PCMH practices with low ratings of patient satisfaction may need to look beyond individual PCPs to communication within and across teams.” As long-time Marvel Comics founder and legend Stan Lee often said, “’Nuff said.”

Refine processes, communicate with patients, and talk to RxLive

Again quoting the AHRQ report, “As primary care practices [and other] adopt a team-based model of care, a significant challenge is identifying and providing them with the structures, processes and other types of support (such as training) they need to facilitate and sustain effective communication among provider team members and develop and maintain good intra-team relationships. Effective communication is essential in ensuring that care is continuous and patient-centered, as well as coordinated and coherent; it is the pathway through which team members become aware of each patient’s needs, culture, values and preferences, and understand one another’s role in delivering care to the patient.”

Let us help

This is why RxLive was founded…to act as a fully integrated extension of a practice or healthcare organization’s in-house team, delivering specialized and expert insight and recommendations regarding a participating patient’s medications and ongoing management. Let us know how the RxLive skilled clinical pharmacist team can help you deliver the next generation of patient- and team-centered effective care by contacting us anytime at

* Advanced Primary Care: A Key Contributor to Successful ACOs, 2018 Evidence Report, Patient-Centered Primary Collaborative

Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.