An action research study of the evolving team member roles in a team based model of health care at the Mayo Clinic

There is a significant need to change the primary health care delivery model from being primarily a physician based model to a team based care (TBC) delivery model. The effective TBC delivery model will be a patient centric interdisciplinary team.;There are multiple reasons for this needed change. The present system is not delivering the desired outcomes. Secondly, people are increasingly experiencing chronic disease issues which are best cared for by a team of professionals over a period of time. Third there is a shortage of primary care physicians particularly if all of the urgent, chronic illness and preventative needs of the population are to be addressed. Fourth, the Accountable Care Act is providing health care insurance to people who historically not had insurance thus increasing the overall healthcare expenditures. Lastly, the Institute for Healthcare Improvement's (IHI) emphasis on the value of healthcare delivered via the triple aim concept (i.e. increasing the value of health care, improving the health of a population while reducing the cost of health care) is pushing all providers of healthcare to identify ways of delivering care that is deemed to be of higher value.;This dissertation will study the evolution of a primary care practice to a TBC delivery model via two research methodologies (action research and semi-structured interviews) within the Southeast Minnesota (SE MN) Region of Mayo Clinic Health System. The scope of this study was limited to one small team within the TBC. This team was the care coordination team.;Two care coordination models have historically been used within Mayo Clinic SEMN. One was the Care of Mental, Physical and Substance Use Syndromes (Compass) Care coordination model which focused on patients diagnosed with depression and either diabetes or coronary artery disease while the second care coordination model is the adult complex care model which was designed to "provide intensive, individualized services to patient with multiple chronic or serious health conditions who are determined to be at high risk" (Mayo Clinic Office of Population Health or OPHM, 2015). There was a need to merge these two care coordination models into one which was named the Hybrid care coordination model. The hybrid model was developed using the learnings of the two care previous care coordination models.;Action research was utilized to study the care coordination evolution into the hybrid model over a six month time frame. Action research is cyclical and iterative with the following steps: planning, acting, observing and reflecting. Reflections and learnings were used to develop additional cycles of action research to evolve the care coordination model. .;This action research study of the evolution into the hybrid model care coordination model identified 16 broad cycles of change that could be placed into the thematic categories of infrastructure, clinical, communication and operations. These themes were also identified through the semi-structured interviews. The findings of this research study were then correlated with the Grumbach and Bodenheimer's (2004) description of a cohesive care team.;The merging of the two care coordination models into the one hybrid model is a microcosm of the future blending of care models that will need to occur as we move from a physician centric model in a fee for service world to a patient centric team based care model. This study was limited in duration, to one geographic region and to one type of type of care team within primary care. The findings of this study should be validated by other studies of care systems moving into the TBC delivery model.;Action research was found to be a helpful tool in facilitating the care coordination model change. As primary care continues to evolve, action research may be one tool that can be used not only to study these changes but also a means to facilitate the multiple changes needed.