A team approach that incorporates case management techniques can work well in helping healthcare organizations reduce readmissions, ED visits, and costs.

  • One team model in Omaha instructs healthcare professionals to work with students to provide high-quality and efficient care to an underserved and low-income population.
  • One of its goals is to reduce staff burnout through a philosophy of collaboration and positive focus.
  • Morning huddles include offering testaments of gratitude for fellow team members.

Two different techniques highlight success in reducing healthcare costs and readmissions. What they have in common is a focus on teams.

Developing the right skills and putting the right team in place are key to success, says Hallie Bleau, ACNP-BC, CCM, assistant vice president of transitional care management for Northwell Health Solutions in Manhasset, NY.

A team huddle serves as a daily organizer, giving the team time to discuss safety factors, new issues, or red flags, says Thomas P. Guck, PhD, professor and vice chair in the department of family medicine and a psychologist with Creighton University School of Medicine in Omaha.

The team works well when it is not divided according to disease types, Bleau notes. “We’re taking care of a lot of different disease types, so we didn’t look for a nurse practitioner who is expert in joint replacement, pneumonia, or chronic obstructive pulmonary disease,” she says. “We looked for people with broad medical/surgical backgrounds who are clinically competent and can handle whatever comes their way.”

The key is to find people with the right personalities and skills sets. It also helps if they are familiar with making home visits in the community, Bleau adds. (See story on how Northwell Health set up its program in this issue.)

One study showed that high-risk patients targeted by a team-based collaborative experienced a 16.7% reduction in ED visits, 17% drop in hospitalizations, a 48.2% decline in total patient charges, and a decline in hemoglobin A1c levels.1

“There’s been a movement among academic institutions, healthcare institutions, and other healthcare organizations to move toward providing good quality care and education and still reduce costs,” Guck says. “We use the model of the Triple Aim, which includes looking at the health of populations while providing a good experience of patient care and reducing costs.”

The Triple Aim is a framework developed by the Institute for Healthcare Improvement. (For more information, visit: http://bit.ly/2Zubi6B.) Creighton University has added a fourth element — provider burnout — making it a quadruple aim. “How do we improve the health of populations?” Guck says. “One barrier is health provider burnout.”

Their goal was to more efficiently serve a low-income and underserved population. A recent partnership with an academic institution and a clinical healthcare system made this possible. “We partnered with CHI — Catholic Health Initiative — several years ago,” Guck says. “Because of the partnership, we consolidated some buildings and functions. This led to moving our teaching hospital and closing the hospital on the Creighton campus.”

Creighton wanted to ensure the organization was serving citizens around the university, so the institution constructed a new building to support patient care and serve as a learning laboratory for health science students, Guck says.

“We are teaching future healthcare workers, while also providing healthcare services at low cost to an underserved community,” he explains. “We designed the building in a way to utilize healthcare teams; it’s an interprofessional, collaborative care model.”

The program’s success in reducing ED visits, hospitalizations, and costs shows that the model works, he notes. “A lot of healthcare organizations are saying, ‘We don’t want to have students in our organization or collaborative practice because it slows us down or is too costly,’” Guck says. “We show that you can both train students and provide higher quality care.”

The next question is whether the program will sustain its results. “We now have a new cohort, where we’re looking to replicate those findings; we’re optimistic, but not ready to share results yet,” Guck says.

The health system also looked at staff satisfaction and engagement to assess provider burnout. These findings also have been positive. “People like working in this model and find it uplifting to be valued as team members,” he says.

The following are some of the ways the program works to enhance patient outcomes and reduce costs:

• Make it a team effort. A team of professionals meet to discuss patients’ needs and solutions. The team consists of occupational therapy, physical therapy, master’s-level behavioral health, nurse navigators, physicians, psychology, and others, as needed. The team works with patients to conduct previsit planning before meeting with the primary care doctor, Guck says.

“We see if the patient has had hemoglobin A1c drawn or if the person is depressed and seeing a behavioral health professional,” he says. “We see if the person has back pain and is going to the emergency room.”

The team continuously assesses whether patients could use other services offered at the facility. “Every week, a resident would present the patient, and we’d discuss the case to see what other things we were doing and how it could help,” Guck says.

• Increase staff morale. Morning huddles cover safety issues, clinical matters, new guidelines, and announcements. They also take time for gratitude, Guck says.

“In the huddle, we all say, ‘I’m really grateful for Mary because she helped me today and can really talk to patients in ways that are so kind,’” he says. “That’s part of staff engagement.”

The idea of boosting staff morale and promoting team camaraderie was seminal to the program. “The week before we opened the clinic in 2017, we really worked hard on conflict engagement,” Guck says. “We embraced the idea that we would have conflict and we can handle it successfully.”

The organization provided staff training with two important slogans:

  1. “We’re all teachers, and we’re all learners.”
  2. “We assume positive intent.”

These two principles guide staff interactions. This way, the more experienced employees can keep in mind that they also can learn from the students and newer staff. “If I have conflict with someone, I assume they are coming at this from a positive perspective, even if we disagree,” Guck says.

• Share values. Creighton and CHI are partners that share similar values about providing service to the poor, Guck says.

“The two organizations have shared values to the point where Creighton’s larger university system has incorporated interprofessional education and collaborative practice into their corporate plan,” he explains. “This is extremely important, but we’re also training the next generation of physicians.”

The goal is for all of the partnership’s healthcare providers to share this model of care, which has been incorporated into the strategic plan, he adds. “This makes it easier for all of us to be champions because we feel like our organizations have our backs,” Guck says. “They said to go out there and develop this practice in the new building.”

• Provide warm handoffs. At-risk patients are provided warm handoffs. For instance, if the patient may benefit from occupational therapy, the team member might say, “Let me walk you down to the occupational therapy clinic and introduce you to Morgan,” Guck says. “The patient meets the therapist right then, if they can.”

• Provide interpretation services. “In our clinic, about 50% of our patients are refugees, so interpreter services are really important,” Guck says.

The clinic’s interpreters represent many different languages and dialects, including languages of people from Nepal, Somalia, Sudan, and Syria. “Any dialect we don’t have available we can make available by phone,” Guck says.

• Hold weekly meetings. Daily huddles are brief, five to 15 minutes, for the purposes of organizing the day. The weekly meetings allow the team to discuss cases and problems.

“Say a person comes in with diabetes, and we would be looking through the record and say, ‘This person never saw the diabetes educator. Let’s make sure Susan can see her,’” Guck says. “Or maybe we would find out the person needs medication, but they don’t have transportation to get to the pharmacy to pick up prescriptions. We have Creighton’s pharmacy school as a clinic in our building, and patients can get medication before they walk out the door.”

The team serves patients well, but also serves students, giving them a hands-on education in how to provide quality, cost-effective healthcare, Guck says.

“We were conscious and intentional about the culture we wanted to develop in the building,” he explains. “We’re all teachers and learners and assume positive intent from academics and from healthcare providers. We’re all melded together.”


  1. Guck TP, Potthoff MR, Walters RW, et al. Improved outcomes associated with interprofessional collaborative practice. Ann Fam Med 2019;17(Suppl 1):S82.