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January 2, 2023

Building and scaling your team-based care model

Last week, Awell Co-Founder and CEO Thomas Vande Casteele hosted a panel discussion with Jamie Mayerson (VP Operations, Maven Clinic), Joel Haugen (CPO, Crossover Health), Dr. Ajay Haryani (Clinical Systems Director, Galileo) and Sandy Varatharajah (Director Strategy & Ops, firsthand) to discuss ways to build and scale a team-based care model. Watch the full panel discussion here. 


Our conversation was filled with a ton of golden nuggets, but here are our favourites: 

  • Make sure you have a dedicated product manager who keeps the care team's voice heard (Joel Haugen, Crossover Health)
  • Hire a rockstar compliance person with been-there-done-that experience who e.g. knows the best credentialing or licensure vendor (Jamie Meyerson, Maven Clinic)
  • Be really intentional about taking folks from the traditional healthcare system and bringing them into a younger startup environment - get them up to speed with e.g. Slack, email... It will bite you in the butt down the line otherwise (Dr. Ajay Haryan, Galileo)
  • Track the engagement measured by successful outreaches - how often are you touching base with a member and how much do they reach out to you? (Sandy Varatharajah, firsthand)

Quick CareOps recap

If you are already familiar with the terms CareOps and care flow, skip this section and feel free to go straight to the key takeaways.

What is CareOps?

CareOps is a set of practices and tools to build, operate and improve software-enabled care flows. It applies principles from agile software development, quality improvement and design thinking to healthcare processes.

CareOps brings people from clinical, operations, product, data and compliance teams together, overseen by strong clinical leadership. Ultimately, CareOps increases a provider organization’s ability to deliver higher quality care at lower cost and drive improvement cycles more frequently than its peers.

For more context on CareOps, read What is CareOps and why do we need it?

Isn't CareOps the same as clinical operations?

Clinical operations or clinops is a function that helps making sure care is getting delivered.

CareOps is a cross-functional practice to design, implement and optimize software-enabled care flows that power clinical operations.

What are care flows?

The central concept of CareOps is the “care flow”. At different care providers different terms are in use for this term, such as care program, care pathway, care plan, patient flow, patient journey, care journey, clinical protocol, care process, (clinical) service line, care process model, clinical workflow or even digital therapeutic.

In essence they’re all sequences of activities completed by a care team and/or patient to maintain or achieve a desired health status for that patient.

Care flows are often defined at the medical condition / population level: a care flow for “Anxiety”, “Type 2 diabetes”, “Total joint replacement with obesity for 65+”, “Menopause”, “Sexual health for LGBTQ+”, “Discharge after surgery”, etc. and can be patient facing only, care team facing only or include activities for care team and patient.

We’ve used “care flow“ as an umbrella term in the panel discussion.


Thomas Vande Casteele: What’s the biggest value of team-based care?

Sandy Varatharajah: The biggest value of team-based care is engagement. It is impossible for any one person to address all of a patient's social and physical needs, but a team-based approach does get you a little bit closer. And if you believe that shared lived experience is a powerful broker in building trust and getting individuals to change their behavior, and ultimately change their health outcomes, then the team-based approach is the way to go. 

Jamie Mayerson: The hallmark of Maven’s team-based care model is around access. At Maven we have over 30 specialities. Half of those are classically licensed MDs  (OB-GYN, PCP, paediatricians…) and the other half of those specialities are coaching and wellness focused. The beauty of our model is that we have all these specialities on one platform where those providers not only have the speciality and sub specialities to answer the breadth of member questions but can also refer to one another and talk to one another.

The biggest value of team-based care to Maven is member support, member engagement and member satisfaction. Additionally, I would also say the provider satisfaction component because a big outcome of a team-based care model is that providers are answering the questions they're meant to answer.

You have a reproductive endocrinologist answering more high-risk cases or questions that are more complex, versus a reproductive nurse that's answering best practices or tips and tricks when you're injecting yourself for the first time with IVF drugs. 

Joel Haugen: To me having team-based care means you have a team that builds trust, that keeps that individual engaged, and builds the trust of more than a simple singular episode or a singular symptom, but now managing their holistic needs ongoing. It’s  critical to drive that relationship to be able to be there in a time of need, that we're the ones that call, so I would say the most, biggest value of team-based care is the relationship that it creates.

Dr. Ajay Haryani: I think about team-based care from the lens of the care model. Because if you think about care delivery and service design, there are all these different axes along which you can toggle the type of touch point that you're delivering, right? There's location, home street medicine, virtual, sync versus async, duration of visit, group visit versus solo visit…

But one of the most important and powerful toggles there is who the person is delivering the service. This is where I think team-based care is really potent and powerful. 

From the lens of clinical utility and high-quality care, who that person really matters. For your needs at that moment, patients are happier when they're talking to the right person who can most effectively address that problem, and who knows how to address that problem. 

Thomas Vande Casteele: The clinical team already eats away most of my gross margin as a care provider. So, should I really be expanding that cost further and make my life more complex by embracing a team-based care model? Because I now have to hire, train, set targets for actually a very diverse set of people and it also introduces a big coordination problem, right? My question is don’t the cost to set up and run team-based care models outweigh the value that it brings?

Joel Haugen:  For us, it's establishing your first question is, what is the ROI of a team-based care model? What are we trying to measure in terms of that and acknowledging that it's more than simple claims reduction in year that you measure through an actuarial model. It also has to include the value of the investment for the employer, the retention, the productivity, the recruitment, the physician satisfaction…

But yes, a team-based care model increases costs. And we have to show the value of those costs in terms of utilization, experience, and outcomes – clinical outcomes, financial savings outcomes, etc. 

And then the question you asked around the kind of the tactical of how to work together as a team, I think it starts with culture, who you hire that's engaged and excited about working in a team-based model.

So, for us, they're all salaried people that buy into the model when they start day one at Crossover. And they meet daily in the morning through the huddle concept. Both our virtual team and our in-person teams have that deep cultural integration to work together, and they work down the hall, either physically or virtually, to establish that. And then you need to have the technology that makes it as easy as possible, and to your point efficient as possible, so it becomes cost-effective. 

Not an easy task and we're just starting to kind of push down that journey. There's a lot of work to do, but the results often speak for themselves in terms of the patient's satisfaction or retention. And we have a shortage of physicians, so physicians they want to operate at the top of their license. They want to work with partners and collaborators in this team-based model. So, it actually increases retention and reduces any of the loss of our staff. And that has cost elements too. So, I think that tends to help outweigh some of the investments that we make in the model itself.

Sandy Varatharajah:  I think a big part of the problem is defining even what a team means. Is it just the physician and the MA and the social worker that's working in the clinical room and going from patient-to-patient room? Is it also your practice manager and your schedulers at the front desk that are driving a lot of the efficient operations? Is it also your shared services that are working behind the scenes on tech and ops to drive systems and processes? What about your community providers? 

I don't want to go down the rabbit hole. But in many ways, this question is a very valid one because everyone sitting in this panel and in the audience would answer this question differently, and then therefore solve for a different problem. 

I think it's our job as leaders to abstract that complexity from our frontline workers so that they don't feel penalized every time they're working their absolute hardest, or they're not constantly doing this mental math in the background to figure out things. 

What makes it even more complex is the layer of venture backing, which demands a certain level of growth in a rapid timeframe, plus dozens of contracts, each with their own set of quality measures.

So, our job as leaders to obstruct that complexity and for us three things help:

  1. Intentional technology: right information, right place, right action, This is what Awell and CareOps are all about.
  2. Good leadership: Not charismatic leadership alone, but someone who is able to understand business drivers and can maintain rigorous performance management. If an MA comes to a leader and says, “Why am I chasing a patient for the next two weeks to get them to pee in a cup?” Can they answer why? And can they do it in a compelling way that rallies the team around it. 
  3. Good rituals: Like good tech teams, care teams should have good rituals. They should have a good morning huddle. They should have weekly case meetings, where they're talking about their most complex members. They should have good practices of documenting next steps and having accountability with ownership.

Dr. Ajay Haryani: Throwing care team members at patients is not going to achieve your cost savings.  You have to think very intentionally about what the role of each team member is. Especially as you're bringing in folks who are non-clinicians, you're often undoing a lot of training that the traditional healthcare system has done for them, which is a lot like disempowerment. That's happened for a lot of folks in these different roles. And so, it's a very active process in training those individuals, leveling them up, empowering them and giving them the space to create that impact, which they're not trained to do in the traditional system.

Additionally I would say that, as you bring in these team members, which one of these services can you centralize? Who really needs to be a field-based team and who really can be a central team, and how can you then kind of democratize that impact across as many people as possible? ou don't want to over centralize and commoditize a service that requires that human touch. But being really thoughtful about that trade-off is another way to kind of impact that ROI calculation.

Thomas Vande Casteele: Patient-centered care is maybe one of the biggest bingo words of the past decade, right? But to me personally, it has a connotation that the patient is passive, and that the care team works around and in service of the patients.  So how can we not just the patient, but also involve their family, friends, etc in the care delivery process?

Dr. Ajay Haryani: A fair chunk of my patient panel is a geriatric home-based population. They're relatively immobile. Lots of caregiver support. Lots of caregiver burnout. Many of them have home health aides that are hired by the city or the state there. And so, I think all the time about what's the most effective way to make sure those folks are at the table. And honestly, the simplest interventions are the most powerful in my experience, which is somebody's son or daughter being able to text-in and check in with us when something's going on with their mother, or somebody that they're looking after. And same with the home health aides. 

When you walk into the home treating them as a part of the team up front, so it's not that they walk out of the room and you go sit next to the patient, but you bring them back in and you sit in a circle and have a conversation together, you give the home health aide the phone number of the practice to say, you text in if something else happens, and you make them feel just as kind of accountable, but also just as empowered to be a part of that care team. 

And then, there's honestly an element of even kind of coaching and leveling up that I think everybody who works in geriatric care does for these populations, which is, how do you actually help the caregivers, the home health aides. All of these folks both access the resources that they need, but also just support the patient in any way they can. 

So, I think there's a cultural component and then there's a bit of a tactical, just opening up those lines of communication and making them very low activation energy. Welcoming that inbound, I think goes a really far way. 

Thomas Vande Casteele: One of the things I hear coming back again, and again, ismany different roles, lots of different locations, synchronous and asynchronous modalities. So, what that makes me think about isa rock band doesn't need a conductorn orchestra So, at what size does a care team start needing somebody who coordinates things before things start falling apart?

Jamie Mayerson: It comes back to the intentionality of the care plan, which has come up before. For this to work well, we need to know where we're going and the outcomes we're trying to drive. And it can't necessarily be free for all. So, what that means is, for example, when members join Maven, their very first touch point is with their own dedicated care advocate. These are incredible people, largely social worker backgrounds that know Mavens' product in and out. They know all the providers. They know all the sub-specialties. They can match based on member preference or demographic, language, time zone...

So, that's step one. And then, members also go through assessments and will be triaged into specific care plans. So, this arguably, is even a non-human conductor, and that there are a set of actions that we would like this member to follow and complete in order to achieve the outcomes, whether it's reduced anxiety and mental health improvements. Or we've also seen like 20% reduction in unnecessary C section rates because you go through birth planning exercises and get your questions answered quickly. And then, this care advocate will make sure you're keeping on track and will meet with you as many times as you want. 

So, I think in some team-based care models that might make sense for a clinician to be this conductor, I think in other cases, it can be more of a sub clinical care advocate, and every model is going to be different. But that's the way Maven really has been successful thus far.

Thomas Vande Casteele: Today, we're seeing a lot of provider shortages and hiring talented care team members is a challenge. On top of that, those who hire, we are seeing the labor costs are skyrocketing. So what could be a practical tips find skilled clinical staff and care teams in an affordable way?

Sandy Varatharajah: A lot of companies say that they want their care teams to be representative of the patients that they serve. Hence, they hire from the very communities that they serve and I think that's a model with good culture and good career pathing focused on your community teams, not your data scientists or your ops managers.

Joel Haugen: You need to have people that understand the local challenges. They need to understand the food challenge, the way people live in that state, the culture... Patients want to talk to clinicians who look like them, people who have similar backgrounds... Additionally I would say that you need to compensate them appropriately and reward them for outcomes. So, we're not incentivizing our care team members based on their panel sized, we're not asking you to stay up late at night charting CPT codes.

So our secret is that we find ways to get you practicing that type of license with people culturally aligned with you, and focusing where you’re spending much more of your time on patient care than the administrative elements of healthcare, and that tends to not just acquire and engage individuals into our care model, but also retain them.

Thomas Vande Casteele: So, Joel talked about the relationship. Jamie talked about the care advocate being the first touch point. I've heard both Sandy and Ajay as well on the importance of the patient seeing the same care team throughout their care journey. To what extent is that important? Should the patient always interact with a maximum number of the same  members? Should it be at least one person that they build a relationship with and can the rest settle around that with different people or doesn't it really have a proven impact on outcomes?

Dr. Ajay Haryani: The answer to this question really depends on the complexity of the patient that you're managing. Where the patient who has one or two medical problems, less complex, may actually not prefer to have the same clinician and you can just optimize for accessibility and responsiveness. And to achieve that, you need to build a trusted brand. And in many cases, I've seen that patients prefer that. They'd prefer to interact with the brand over then having to sacrifice the other variables there. As you move along the complexity spectrum, the clinical nuance increases there, and you need a stronger, more human centric relationship to make difficult, heavy decisions. And so, that becomes more important. And at the end of the day, you also need that quarterback, that quarterback is more and more important to be a single person or one to two people as compared to the less complex person, just because there's a lot of nuances there that can get lost if you don't have the right systems built to support it.

Joel Haugen: You need to find the right balance and it depends on a few dynamics. The first dynamic is "Was it a good experience?". If it wasn't a good experience, I want to be able to choose someone different. So, don't keep pushing me back to the same person, they didn't have a good experience with. Number two is how important is the tradeoffs of relationship to convenience, and make them balancing that I want someone to respond within a minute or 15 minutes, or I want this trusted partner to respond to me within six to eight hours in between appointments or following up at the end of the day with all of their outstanding items. That is a delicate balance to manage, and finding that balance is really around the population you're serving.

Thomas Vande Casteele: Could you each give a practical tip about what have you realized since the day you started, that if you would know it you would do differently?

Jamie Mayerson: Hire a good provider recruitment team. You need dedicated people focused on this. Clinical recruitment is nuanced, not the same as regular recruitment. Sometimes there's different metrics involved. There are different best practices and building pipelines and sourcing.

And then my other favorite one, and I just say this over and over again, every time someone asks is hire a great compliance person early on who has been there done that because they'll know the best credentialing vendor and the best licensure vendor where you're going to get stuck on processes, how long things should take. When you're building a provider network, if those providers are not credentialed or able to practice where you need them to practice, there's no access.

Joel: From a technology perspective, don't forget the care team. A lot of the prioritized features and functionalities when you're in a tech enabled service tend to lean more on the patient experience, and helping with the features and functionalities that support them. And often we forget about the back end, the laminate cards and the Google Sheets and the other activities that have plagued a lot of these startup organizations for the medical group. 

So, how can we from a product perspective prioritize equally, if not favoring some of the care team needs to make sure that it streamlines their experience that helps with not just efficiency, but patient satisfaction, which we deserve, provider satisfaction, which we just indicated as challenging. 

So, that would be my advice: make sure you have a dedicated product manager, dedicated product analyst, someone who is constantly keeping the voice of the care team, in addition to the voice of the member, front and center as you're planning your technology roadmaps.

Dr. Ajay Haryani: Be really selective and thoughtful about the recruiting team for the different roles that you're hiring for. Getting those care team members very involved in the recruiting process earlier, helps train up that recruiting team to better understand the nuances that they are looking for. Some folks come in with this background, and it's great to have, but the more buy-in you have from those care team members and the more you kind of have a bit of a recruiting champion, is what I do for each type of role, that can work as almost a diet partner with recruiting to continue to iterate and refine what their compass is, the faster you get to finding good candidates. 

And then, the second point I'll make is just thinking really intentionally about folks that you are taking from the traditional healthcare system and bringing them into a younger startup environment, just know the common pitfalls that you're going to run into, know that you need to spend time upfront up getting them up to speed on Slack, email, owning their calendar – like these very micro tactical things, if you ignore them, will absolutely bite you in the butt down the line and create lots of inefficiency. 

And then working really consciously, and this is a little bit less tactical and more kind of wild culture is just spending time talking to those folks and assimilating them into the kind of new culture that they're walking into, which may be very different from where they came from.

Sandy Varatharajah: Don't underestimate how hard it is to get raw, real-time feedback from care teams. Most people we are hiring are coming from work environments where they're actively discouraged for giving feedback. Maybe they've been incarcerated before and that actually curious trauma with giving feedback because you were punished for it. 

And there are lots of ways to solve this. Some companies will embed a central resource, so they're constantly liaising and giving feedback back to the central team. Obviously, this is where the product shines, shadowing your care teams, understanding their workflows, their pain points, but I mean, that may be unrealistic for some companies to hire up or to send people out into the field and to have them spend an entire week shadowing. 

On the other hand, like a lot of our team members have said that they're uncomfortable with Slack or they're not, it takes them a long time to type out feedback offline. So, one way we've done this is asked in one of our markets to have people send voice memos to us because then it's just like, quick, it's there. So, think of creative ways to get that real time feedback and actually encourage it without just saying, give us feedback.

Thomas Vande Casteele: Joel, can you tell us how you as a product leader at Crossover get input from the care team into what products you design and build, and how that will ultimately drive outcomes?

Joel Haugen: I'm very fortunate to have a really strong design and product management team. We have a single dedicated product manager who lives and breathes full-time care team feedback, and develops that into the roadmap of features and functionalities and into the appropriate cycles for squad development, and scrums, etc. 

So, that's part of the product management side of it. On the design side, we have a dedicated researcher, as a part of our design team that does exactly the types of things that Sandy indicated, it’s looking at some of these broader ethnographic challenges looking more holistically at surveys, looking at direct shadowing of our care team members, meeting with the monthly medical group and evaluating some of their key challenges. Some of them are very tactical, like, hey, I don't want to duplicate the entrance of this data here and here, and some of them are more philosophical around how we drive better integration between the team-based care. 

But to us, it starts with the research. It’s always data driven human-centered design, making sure that we are solving the problem and making sure that we understand that rather than just taking orders and moving a button here, really understanding what the problem we're trying to solve for and making it easier both for the care team and the member, and that starts with that research and design.

Thomas Vande Casteele: So, how often can a care team or a care team representative provide input to the product team to co-determine that roadmap?

Joel Haugen: We have established product working teams that has a representative from the medical group. So, we have individuals in the medical group weighing in on how we collect payments. We have a medical group member weighing how we register our members. What push notifications we use to support our large strategic clients on mental health awareness month. 

So, we are there front and center on bi weekly product working teams, not just for their specific needs, but also weighing in on the member experience and all the other priorities we have across all the product working teams. 

Jamie Mayerson: I second all that. I worked so closely with our product team. And the more that clinical and product can work in lockstep, quite frankly, the better. So, make sure that you have cross collaboration readouts, and we also do surveys, engagement surveys, NPs surveys, product surveys, product testing, and have dedicated pods to certain delivery areas that involve clinicians or care team members, as much as possible, quite frankly. So, it's always the clinical requirements, the business requirements, the product requirements taken together.

Thomas Vande Casteele: So, when we look at the clinical world generally changes are only possible if there's evidence that is a good change, right? But when we look at the perfect world, we want to be agile and experiment. And so, can someone comment on how to marry those two mindsets, and where they might fail?

Joel Haugen: We are a measurement-based care organization at Crossover rather than an evidence-based medicine. So how are we improving someone's physical movement? How are we focusing on their behavioral health score? And there may be multiple paths to get there. 

So, by nature, we allow flexibility and creativity within our care team. And similar to having that within our product organization, but there's a delicate balance here around how we drive that standard efficiency, how we make these decisions about failing fast and modifying. We've acknowledged that our care model is never done, we along with the industry need to constantly evolve our care model looking at data. So, again, data driven human-centered design, is the data showing that people are engaged in closing care gaps differently if they go this way versus this way? What's the cost of that? Is that more effective for asynchronous care to solve that problem, or otherwise? 

And so, we partner extensively with the care team. And because we're more measurement based here, because we're focused on the destination rather than the path, it allows us a little bit more flexibility in collaboration with our care team to make changes and to fail and find the right path with them on solving some of these challenges. But it isn't easy. There are constant examples where we've made changes technologically or they've made changes clinically, that we've had to redirect and address and standardize the approach for consistency and for member experience.

Dr. Ajay Haryani: One other thing I'll add there that makes this kind of another layer of complexity. You've got kind of the safety component and kind of clinical values, clinical philosophy, which really comes down to your clinical cultures, stemming from your clinical leaders, and their ability to kind of cross talk both with the folks that they're managing, and with the kind of cross functional leaders of the organization. 

But also, this idea of rapid iteration is antithetical to the way most people that practice in the health care system, and one thing that can do is start to feel almost specific in for your care team members, is they finally get used to a certain process or pathway, and then you decide you're going to change it. They're used to like one-to-two-year iteration cycles and feeling very comfortable in what they're delivering. And so that really requires what we were talking about in the last question, which is buy-in from the care team members in thinking through what those processes are, and getting them excited about it. 

At the end of the day, everybody recognizes the limits of evidence-based medicine, and all clinicians have their own sense of clinical judgment. And when you open up the opportunity for them to be creative and saying "What do you think is the most effective way to actually achieve this outcome?".I think most folks are surprised by how much clinicians are excited to engage with new ways of approaching patient care in that way.

Thomas Vande Casteele: if there is one metric that you want your care teams to look at every day, what is that metric?

Joel Haugen: We surveyed our members to ask if they considered Crossover their medical home. That to us is our North star. Again, going back to that relationship. That's the best proxy for us to say, do our members truly trust us as their health care relationship?

Sandy Varatharajah: I would look at engagement measured by successful outreaches. How often are you touching base with a member? Are they calling in to you and you're having a conversation? Individuals at the center.

Dr. Ajay Haryani: I'll just highlight how often are they calling into you, in my mind, is one of the most intimate surrogates of trust there. Picking up the phone, when you call them is one thing, but then reaching out to you in times of need. and seeing that in your patient panel, I think is really powerful.

Jamie Mayerson: Pretty much echoes all of this, but the score of did this provider resolve your issue? That's a pretty important one.


Quick intro: we’re Thomas and Rik, building Awell - a low-code platform allowing care teams to design, implement and optimize care flows in days, not months. CareOps grew out of our years spent improving CareOps at innovative providers.

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