Transdisciplinary Teams in Primary Care for the Underserved: A Literature Review

For 30 years, effective teamwork has been touted as a means to achieving superior outcomes, better patient satisfaction, improved staff morale, and cost containment. Most would agree that the provision of primary care involves a group of individuals with varied training, experiences and capacities, but cases in which those groups have matured into optimally functioning teams are few. The difference between a group and a team is as follows: "A team is a group with a specific task or tasks, the accomplishment of which requires the interdependent and collaborative efforts of its members."¹

Barriers to the transformation of groups into teams include necessary time and commitment², a lack of agreed-upon common goals,³ perceived status inequalities,⁴ inadequate data to assess impacts of team care on a variety of metrics,⁵ payment systems that do not reimburse teamwork,³ and lack of evidence to support the use of the team model.³ Nevertheless, in its 2001 report, Crossing the Quality Chasm, the Institute of Medicine (IOM) included the development of effective teams as a recommendation for how to improve health care quality.⁶

The question of how best to deploy group members has given rise to several models of team care. The multidisciplinary model involves vertical communication from supervisor to subordinates,² with each member contributing an assessment after applying a discipline-specific skill-set. There is little discussion between team members at any point in the process except to share conclusions.

The interdisciplinary model acknowledges the overlap in knowledge of the different team members and facilitates horizontal communication at many points in the process of evaluating and treating a patient, so that the result of these efforts is sometimes greater than the sum of its parts.² In 1996, the Institute of Medicine recommended the adoption of interdisciplinary primary care teams wherever feasible in order to enhance the "quality, efficiency and responsiveness of primary care (p. 121)."⁷

The transdisciplinary model of care takes collaboration to a still higher level, incorporating ongoing cross-disciplinary education and regulated overlapping roles. This approach explicitly includes the patient and his or her family at all stages as team members, setting it apart from other models of care. By institutionalizing frequent communication (both horizontal and vertical) and by regulating team members' overlapping roles, this collaboration circumvents fragmentation of services along disciplinary lines as well as duplication of services.⁸ This is consistent with the IOM assertion in Crossing the Quality Chasm that "flexibility in role functioning [among team members] may be key (p. 132)" to optimizing care in an increasingly complex medical environment.⁶ The nation's largest payer for health care services for the poor and underserved, Medicaid, agrees, recommending a transdisciplinary approach for all early intervention and support services, suggesting that providers "learn and work together across traditional disciplinary or professional boundaries (p. 1)"⁹ to optimize outcomes. The 2003 IOM Report, Unequal Treatment, which presents an approach to addressing the racial and ethnic disparities in American healthcare, recommends the implementation of "multidisciplinary treatment and preventive care teams (p. 18)."¹⁰ The scarcity of resources in caring for the medically underserved make the transdisciplinary approach ideal in this setting. Role flexibility between support staff can mitigate the impact of absenteeism and weekly shifts in demand for services.³ Provider cross-training (such as the training that occurs when medical staff learn to conduct pediatric oral health screening) can help address the shortage of oral health providers for the uninsured and underinsured, reserving the dentists' time and skills for those individuals needing more intensive interventions.¹¹

This review makes a case for the use of transdisciplinary teams in primary care for the underserved. There is a significant body of literature on primary care teams dating back to the 1960's^12,13,14,15;the authors have chosen to focus primarily on contributions to the literature made in the last decade. In particular, this discussion will endeavor to answer two questions about the implementation of transdisciplinary team care in the primary care setting for the...