Table 4 Structure of the final 8 domain Healthcare Team survey as emerged from analyses

1

Accountability (Acc) α = .844

The PCT (Primary Care Team) team is made up of members with clearly defined roles, such as patient self-management, education, proactive follow up and resource coordination.

The PCT and patients share responsibilities in managing patients’ health.

The PCT is characterized by collaboration and trust.

The PCT works with patients to help them understand their roles and responsibilities in care.

2

IT capacity (IT) α = .874

The PCT uses electronic data to monitor and track patient health indicators and outcomes.

The PCT team uses electronic data to support the documentation of patient needs. ^N

The PCT uses electronic data to develop care plans. ^N

The PCT uses electronic data to determine clinical outcomes. ^N

3

Plan of Care (PC) α = .903

The PCP asks for patients’ input when making a plan for their care. ^N

The PCT helps make care plans that patients can follow in their daily life. ^N

The PCT develops care plans that incorporate plans recommended by other health care providers patients see. ^N

4

Follow-up Plan of Care (FPC) α = .886

The PCT team reviews and updates patients’ care plan with them. ^N

The PCT follows through with the care plan. ^N

The PCT uses patients’ care plan to follow progress. ^N

The PCT helps patients plan so they can take care of their health even when things change or when unexpected things happen.

5

Self-Management (SM) α = .803

Someone on the PCT team helps patients set goals for managing their health.

Someone on the PCT team checks to see if patients are reaching their goals.

The primary care practice/health center has behavior change interventions readily available for patients as part of routine care.

The primary care practice/health center has peer support readily available for patients as part of routine care.

6

Communication (Comm) α = .865

The PCT team informs patients about any diagnosis in a way that patients can understand.

The PCT team helps patients understand all of the choices for their care.

The PCT team considers and respects patients’ values, beliefs and traditions when recommending treatments.

The PCT team’s care coordination activities are based upon ongoing assessment of patient needs.

7

Link to Community Resources (ComRes) α = .896

Someone on the PCT team offers patients the opportunity to learn more about managing their health, such as with group appointments, support groups and patient education.

Someone on the PCT team asks patients about what they need for support, such as care programs, financial services, equipment and transportation.

Someone on the PCT team gives patients information about additional supportive services offered at the practice/health center or in their community, such as counseling programs, support groups or rehabilitation programs.

Someone on the PCT team encourages patients to attend programs in their community that could help them, such as support groups or exercise classes.

Someone on the PCT team connects patients to needed services, such as transportation or home care.

8

Care Transitions (CT) α = .875

When patients are discharged from the hospital, the PCT team is informed about the care patients received from the hospital.

When patients are discharged from the hospital, the PCT team receives information from the hospital about new prescriptions or if there was a change in medication.

When patients are discharged from the hospital, their primary care medical record includes a discharge summary in a timely manner. ^N

When patients are discharged from the hospital and there are test results pending, their primary care medical record includes the test results within 2 weeks. ^N