Ambulatory Team Visits: A New Model for Quality, Cost-Effective Care of Complex Patient Cases?

Deepak Honaganahalli, MD, MPH; Melissa Gateley, BSN, RN; and Evan Neufeld, MA, LPC

Consultant. 2017;57(1):8-10.


ABSTRACT: The patient-centered medical home (PCMH) model is expanding the scope of and resources for the delivery of health care. One example of implementation of the PCMH model, the ambulatory team visit, is described, including details about the specific team members and about the course of a team visit. One year of results is presented, along with an assessment of the potential disadvantages of the ambulatory team visit concept and suggestions for possible improvement to its implementation and long-term success.

KEYWORDS: Patient-centered medical home, ambulatory team visit, team-based care, behavioral health, primary care, community health, integrated health, population-based health

The delivery of primary health care in the United States has become increasingly complex due to various factors that are beyond what may be seen as traditional medical issues. The scope of care of today’s primary care practice has widened to include challenges such as patients’ psychological health, socioeconomics, access to health care, political factors, health care costs, and the aging US population.1 In an effort to meet these demands, the health care delivery system is moving toward the patient-centered medical home (PCMH) model to manage care with a team rather than with a single provider.2 This shift in focus is designed to improve the efficacy and safety of health care, address the fragmentation of health care delivery, and engage patients to become active participants in their own health care.3

As the practice of health care evolves, so too must the delivery of health care services. Hospitals have established robust care teams and team visits to improve acute care outcomes. In an effort to provide more comprehensive and timely care, our health care center has adapted this approach to an outpatient setting to create an innovative ambulatory care team to provide primary care to patients with high-risk, complex cases. Over the course of a year, we created and implemented an ambulatory care team at one of our health centers that is PCMH accredited by the Health Resources and Services Administration. The facility is one of 23 health care centers within the Peak Vista Community Health Centers system in Colorado Springs, Colorado. As a Federally Qualified Health Care Center, as designated by the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services, Peak Vista cares for a population of more than 80,000 underserved individuals. Our results suggest that the creation of an ambulatory care team can provide one route to improved health care outcomes in an outpatient setting.


The traditional US health care model has created a world in which health care providers are expected to wear multiple hats: caregiver, prescriber, counselor, resource navigator, and more. In an effort to keep pace, physician-patient interaction has developed a tendency to become a mechanical, goal-directed activity. In primary care, the scope of care has become too broad in many ways to be managed by a single medical provider. The evolution of care has brought about the addition of various team members to share the responsibilities of providing health care. As a result, a health care provider is able to have more face-to-face interaction with patients and to spend more time listening to their concerns and building rapport. However, the simple addition of staff does not necessarily mean better care.

In traditional team-based health care, different members of the team are involved in the health care of a patient at different times. For example, a patient is roomed by a medical assistant (MA), seen individually by the medical provider, and then may be seen by a series of other staff members such as a nurse, a behavioral health professional, and a patient resource navigator. With the addition of each individual team member with his or her own specific focus, communication among team members may become a barrier to optimal patient care. For example, information might get lost or changed in translation, patients might not remember details of the treatment plan created during their visit, distracted providers might struggle to keep patients’ whole health picture in focus, and patients might have to repeat the same information to different team members. Any one of these difficulties in communication can lead to patients’ frustration and lack of satisfaction and increase the risk of negative health outcomes.

With these challenges in mind, we created an ambulatory care team at our community health center to address patients’ health care needs. The core ambulatory care team includes a medical provider, a clinical team nurse (CTN), an MA, and a behavioral health provider (BHP). In addition to this core team, the peripheral team could include a patient resource navigator, a case manager, a scheduler, a dietitian, a dental hygienist, a pharmacist, and an office manager, among others. Some team members’ roles can be bundled or overlapped. For instance, nurses can be trained in case management, and MAs can be trained to serve as a medical scribe during visits. It is very important that no matter how a team is staffed, the identified roles and responsibilities of each team member have been detailed and discussed.

Team Members

The CTN has multiple roles and has the most dynamic position on the team. The traditional clinical responsibilities of the CTN include triage, counseling, nursing care, nurse visits, preventive interventions, and patient education. In our ambulatory care team model, the role of the CTN has evolved to include population health management, case management, community resource navigation, and administration. The CTN is involved heavily in each visit to help patients navigate the complex health care system. The CTN also communicates with home health agencies, outside providers, and others and often is able to communicate on behalf of the primary care provider. By communicating with external resources, the CTN is able to bring the entire picture of the patient’s case to the primary care provider before a visit with the patient.

The role of BHPs in the integrated health care model has shifted away from providing specialty behavioral health services and toward a more consultative and brief intervention model. BHPs have the opportunity to become more involved with patients’ behaviors that directly affect their medical conditions, including identifying underlying behavioral health problems, addressing psychosocial stressors, using motivational interviewing techniques, referring to specialty behavioral health services, coordinating care among providers, and providing brief interventions. One important quality of a BHP is the ability to be flexible in service delivery, given the greater opportunity to reach a population of patients who may never seek any type of behavioral health service. This flexibility also offers patients continuity of care and an ongoing link with the entire care team.

Action Plan

Once the ambulatory care team was developed and the members’ roles defined, the flow of a typical patient visit was considered. For our team, the first action of the day is the huddle. The needs of the patients and the team are identified as part of morning briefings, during which the entire team meets to coordinate care, to set goals for patients and team members, to review individual preventive care strategies, and to identify potential barriers. In keeping with the patient-centered model of care, each patient also provides a voice in the direction and delivery of care during the visit. 

As this process evolved and was repeated numerous times, our team became increasingly cohesive over time, and the approach to the care of individual patients shifted given the team members’ specialties, interests, level of rapport, and individual effectiveness with a particular patient. The final step of the flow is a debriefing after a visit, to identify and address any unexpected problems that may have arisen during the visit.

During the visit, all team members actively listen to a patient and create a working treatment plan. It is important that a new patient to the clinic have his or her first appointment with the entire team for introductions and to begin building rapport. Subsequent visits may include the whole team or only a few members, as identified and discussed in the huddle. Team members offer their particular perspectives and services during the visit. The cohesiveness of the team provides an atmosphere of care and a sense of responsibility for the treatment plan. Trust and rapport is built and shared among team members and the patient together, rather than one team member at a time. 

Having individuals from different health professional backgrounds listen to the patient’s concerns can provide a more complete picture, which in turn can provide a better treatment plan. In addition, a patient’s verbal and nonverbal cues can be better grasped with multiple team members attending to the patient simultaneously. The patient gets to know the team members and their particular roles, clarifying who is responsible for what aspects of care.

This model also enhances staff education and sharing of knowledge. For example, the BHP can learn about the medical treatment of diabetes from the medical staff and also can model motivational interviewing techniques for the rest of the team during the same visit. Ultimately, this approach makes time management more effective, because patients can contact the particular team member who is best suited to help with a particular need. The key component of increasing patient health outcomes is patient engagement,4 which can be greatly enhanced with the use of this model. The model can be seen as a one-stop shop for patients with complex cases.


Our care team chose to focus on patients with diabetes as the primary target population for change, owing to the complexity of the illness, its treatment, and its comorbidities. Although each team member shares responsibility for providing different aspects of care (eg, the MA is responsible for foot examinations, immunizations, and depression screening; the CTN is responsible for ophthalmology consultations, preventive screening, and case management aspects; the BHP is responsible for the evaluation of depression, medication adherence), improvement in levels of glycated hemoglobin A1c was monitored as the target for change.

Our business intelligence department generated reports and monitored patients’ A1c control during a 1-year period. Among the team’s panel of 745 patients, 183 (24.6%) had diabetes. Of those 183 patients, 48 (26.2%) had an A1c level greater than 8%, and 120 patients (65.6%) had an initial A1c level less than 8% at the beginning of the study. The remaining 15 patients with diabetes did not visit during the time period of the study, had inaccurately received a diagnosis of diabetes, or were older than 80 years (our business intelligence department did not track statistical information on patients in this age group). Of the targeted 48 patients with an A1c level greater than 8%, 33 (68.8%) had improvements in their A1c level after 1 year. A closer look at the outcomes data of these 33 patients revealed that 25 (52.1%) improved their A1c level to less than 8%, 6 (12.5%) improved their A1c level to less than 9%, 1 improved his A1c level from 12.2% to 10.1%, and 1 improved his A1c level from 17.3% to 12.1%.

Given that this is a concept-driven model, we believe that ambulatory team visits could be implemented in various ways in a variety of health care settings, from a solo provider practice to a large group practice transitioning to team-based care, as long as there is more than one health care professional providing direct patient care in that practice. Although some of the peripheral support team members changed, the essential components of our core care team (medical provider, MA, CTN, and BHP) remained constant throughout the year. We believe it was important to have that consistency of team members to encourage ongoing rapport with patients as well as to minimize any confusion among  staff and patients alike about team members’ roles and responsibilities. As such, we would recommend any team to focus on continuity of care and roles rather than the size of the team.

In our efforts to implement the ambulatory team visit model, we found it necessary to begin by limiting our focus to several team visits per day. To do so, we narrowed our target population not only by selecting patients with a specific condition (diabetes), but also by identifying (through morning huddles) the most complex cases among this population of patients. Doing so afforded us some additional time to practice our roles, identify any barriers within the team itself, debrief about the results of our approach, and ultimately fine-tune the efficacy of the team. Over the course of the year, we found we needed less time for morning huddles and debriefing, which began to occur on an as-needed basis toward the end of that year.

Potential Pitfalls

We have identified only a few drawbacks in our own implementation of this model. It does involve a high level of communication and a strong willingness of team members to work as a team above and beyond what is required in the more traditional health care model. We have found that a shared attitude of care and responsibility are paramount to the success of a cohesive team.

Another drawback we considered is the potential for a patient to be overwhelmed by the number of staff members present during a team visit. Although some patients did report initial anxiety, very few refused care or reported discontentment with the model, especially given the fact that we encouraged their voice as part of the care plan. In an effort to minimize this anxiety, our MA took the time to introduce our patient-centered team approach concept during the rooming process, before the rest of the care team arrived, to prepare the patient for what to expect.

Another disadvantage we considered was the potential for the over-delivery of health care services for patients without complex cases. Effective planning and morning huddles ensured the best use of resources and the timing of the availability of other team members.

Although there is currently no quantifiable financial incentive to implementing this model, patients receive higher quality and more comprehensive care, including preventive care and case management. This could reduce patients’ short-term and long-term morbidity, thereby resulting in lower long-term health care costs, as well.

Deepak Honaganahalli, MD, MPH, is a board-certified internist at Peak Vista Community Health Centers in Colorado Springs, Colorado, and an assistant clinical professor of medicine at the University of Colorado School of Medicine in Aurora.

Melissa Gateley, BSN, RN, is a registered nurse at Peak Vista Community Health Centers in Colorado Springs, Colorado.

Evan Neufeld, MA, LPC, is a licensed professional counselor at Peak Vista Community Health Centers in Colorado Springs, Colorado.


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