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Management Brief No. 182

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Management eBriefs
Issue 182 February 2021

The report is a product of the VA/HSR Evidence Synthesis Program.

What are the Effects of Different Team-based Primary Care Structures on the Quadruple Aim of Care? A Rapid Review

Team-based primary care has become a predominant model to provide accessible, high-quality care, and meet the quadruple aims of improving patient experience, population health, the work life of the healthcare workforce, and cost-effective care. VA re-organized primary care delivery via the Patient Aligned Care Team (PACT), which is based on the medical home model. Within the primary care team are smaller units called teamlets. As VA continually seeks to improve the quality, cost, access, and wellbeing of the healthcare workforce, the question arises whether other compositions of a teamlet – or the larger team – might produce improvements in any of these domains? This systematic review was done in response to a request from the Office of Primary Care regarding team composition and outcomes.

VA’s PACT teamlet is defined as a primary care provider (physician, physician’s assistant, or nurse practitioner), a registered nurse (RN), a licensed practical nurse (LPN), and a clerk or medical support assistant. Each teamlet is expected to provide primary care for approximately 1,200 Veterans.

Investigators with VA’s Evidence Synthesis Program (ESP) Center in West Los Angeles, CA searched OVID online from inception to May 29, 2020. After reviewing 215 abstracts, they used 14 publications for this review, including 5 studies that showed comparative research of different team structures, 8 studies that added a provider in context of team-based care, and 1 study that assessed outcomes when going from a structure that was not team-based to a structure that was team-based.

Summary of Findings

The evidence for an optimal teamlet or team structure is very sparse. Other than adding a dedicated chronic care manager, there is no evidence above low certainty that any team structure is optimal. Complex patients almost certainly benefit from additional skills (beyond the basic teamlet of provider, medical assistant, and nurse) in the team writ large (i.e., pharmacist, chronic care manager, etc.). 

Implications for VA

Because investigators found only one study in a VA population, which was about single versus multiple team membership roles and not about specific team members, they can only speculate as to the applicability of the remaining findings to VA populations. However, VA would seem to be ideally placed to provide experimental evidence about how teamlet and team structures can be optimized. Almost every VA of sufficient size organizes their teamlets into larger units (like Red, Green, and Blue teams). This would allow for controlled comparisons of differing team and teamlet structures, with other contextual features being internally controlled (i.e., senior leadership, incentives, and the electronic health record-EHR).

Research Gaps/Future Research

The evidence on what matters in terms of the composition of a PACT teamlet is very sparse, consisting of a few hypothesis-testing studies that address only partial aspects of the question, and modeling studies. If future research was conducted in VA, data collection could come directly from the EHR. Detailed information would need to be collected about patients’ chronic conditions and social needs as the model by Meyers considers these important variables when determining optimal team composition. An agreed-upon metric for evaluating performance would facilitate comparisons of results across studies.

Shekelle PG, Begashaw M. What are the Effects of Different Team-Based Primary Care Structures on the Quadruple Aim of Care?: A Rapid Review. Los Angeles: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2021.

To view the full report, go to

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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