Team-Based Care

Team-based care is the delivery of health services to patients and families by multiple health providers and support services in a manner that is coordinated across settings and between patient visits. In 2012, the Institute of Medicine articulated five core principles of team-based care:

  • Shared goals that reflect patient and family priorities.

  • Clear roles and responsibilities that optimize the team’s efficiency.

  • Mutual trust fostering shared achievement.

  • Effective communication by all team members across all settings.

  • Measurable processes and outcomes to track and improve performance immediately and over time. is built to enable the experiences necessary for care teams to effectively manage complex care for high-needs patients.

Complex Care Management

Patients with multiple chronic conditions and complex medical and social needs require different kinds of care teams. They also need support from family members, caregivers and community resources to help them achieve their health goals. There are common themes among successful complex care management programs:

  • Shared goals that reflect patient and family priorities
  • Provider groups taking on more risk for overall costs

  • Care coordination as a key operational focus for care teams

  • Team training requirements for adapting to new models of patient care

  • Data being applied to identify at-risk patients and initiate interventions

  • Organizations seeking continual improvement through advanced measurement and reporting bridges the gap between population health data analysis and team-based care for complex patients.

Disruptive Innovation

What defines a high-performing healthcare organization? Is it culture? The history or leadership of the organization? The unique community it serves? The size of the health system?

These are key questions posed by Clayton Christensen, professor at Harvard Business School. Disruptive innovation is the process by which a new idea takes root in a market and eventually displaces established ways of thinking.

Healthcare is undergoing a transformational shift from fee-for-service economics to value-based care. At the heart of this shift is a new emphasis on team-based care coordination. is purpose-built to meet this challenge. In 2015, raised $8.4M in Series A funding led by Clay Christensen’s VC firm, Rose Park Advisors.