Care teams: A new strategy is revolutionizing healthcare

“With urgent care, you are seen for an acute event — a one-time visit,” says Taylor Nasby, RN, director of Clinical Care Management at GBMC. “With GBMC primary care offices, you develop a relationship with all staff members. The office wants to see you when you're doing well and they strive to keep you healthy.”

Making full use of the GBMC primary care system and lessening the need for urgent care means patients are seen by a team of doctors who have access to medical records — including completed labs and imaging studies — and can more accurately anticipate patient needs.

“This can save money, time and decrease unnecessary procedures,” says Robin Motter-Mast, DO, department chair of Family Medicine and medical director of Clinical Integration and Implementation at GBMC. “Your medications are available and accurate with historical information. This helps to reduce prescribing medications that may not have worked in the past or have caused problems for the patients or (when) they don’t remember the details.”

If you are seen in any of our offices, your medical record is viewable by the providers caring for you.

To ramp up its care management, GBMC created two-person “care teams” consisting of a nurse and resource specialist. The nurse provides additional health coaching and education on chronic illnesses while the resource specialist helps patients obtain medications, transportation or specialty care referrals, for example.

“This team helps the healthcare provider manage the patients and their needs in between scheduled appointments,” explains Dr. Motter-Mast, who adds that the teams also provide services to patients who have been seen in the emergency room or hospitalized. “They reach out to them to see if they are doing well, or if they need additional help to set up services that were noted to be needed as a result of their ER or hospital visits.”

Services provided by a care team are by no means a one-size-fits-all scenario. “Each patient is an individual with different educational needs and different barriers they face,” says Nasby.

The process starts when patients meet with nurse care managers at a GBMC office or speak to one by phone. The nurse listens to what is important to the patient in terms of their health and well-being.

“We build a relationship with the patient,” Nasby says. “We’re not going anywhere, and we want the patient to know and understand they can rely on us for their healthcare needs. Education goals are individualized to meet them where they are now and where they want to be in their health.”

As an example of the personalized attention rendered by the GBMC care teams, Nasby cites a patient who was handed an unexpected diagnosis of diabetes when visiting her primary care physician.

“As the RN care manager, my first meeting with her was just to let her cry,” Nasby recalls. “With her husband present, we went over how to use a glucometer (home testing kit for blood sugar levels). I had each of them ‘teach’ me like I had taught them, then I had her actually go through the steps and perform a finger stick and test her blood with the glucometer.”

Nasby and the patient met a few more times in the office during educational sessions focused on diabetes, medications, diet and exercise. Nasby called her daily for the first two weeks while the patient was adjusting to her diagnosis and met her in the office for follow-up appointments with the physician. The calls extended weekly, twice monthly and then monthly.

As a result of this care and attention, says Nasby, “She was able to reduce her hemoglobin A1C from 11 percent in February 2014 and maintained at 6.3 percent in September 2016. She has also lost 21 pounds and continues to maintain a healthy lifestyle. She was able to stop insulin injections and is only on oral medications to maintain her diabetes progress.”

Another popular aspect of GBMC’s team approach is the fact that it caters to patient schedules.

“In the past, the majority of healthcare occurred only when a patient visited a primary care provider,” says Dr. Motter-Mast. “Now there are tools in place to help patients manage their healthcare even when they get too busy to come to the doctor.” And when a patient needs to be seen and schedules are tight, GBMC’s primary care locations offer extended weekday hours as well as weekend hours, for sick visits.

Dr. Motter-Mast recalls how GBMC’s approach benefited several patients.

“We've had a 50-year-old woman diagnosed with early colon cancer as a result of our outreach encouraging her to have a colonoscopy. She admitted she would probably not have done this for a few years if we had not contacted her and helped her set up her test. We have another woman whom we were able to persuade to get her mammogram done. She was diagnosed with breast cancer and was able to receive treatment right away.”

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—Joe Yogerst for Greater Baltimore Medical Center