Table 3 A summary of the I-TEAM model.

From: Developing an interprofessional collaboration for COPD patients in primary care: a participatory action research approach

Adjustments to usual primary COPD care.

Phase 1: When referring to secondary care, a more comprehensive referral letter is provided by the GP and/or practice nurse.

Phase 2: The diagnostic phase is supplemented by the inclusion of eligible patients. Included patients have: COPD, multiple TTs, receive care in one of the regions by ≥2 HCPs, are anticipated to benefit from IPC.

Phase 3: Referring the patients back to their GP now includes a more extensive referral letter. It contains a concrete plan with TTs per profession and advice on whether a referral to a certain profession should be realised.

Phase 4: The initiation of the IPC-team is assigned by the GP or practice nurse. This includes referral to the advised HCPs, inviting all involved HCPs to a consultation group, and distributing the information letter to these HCPs.This IPC-team must reach consensus on the IPC process. Three discussion points are mandatory.

Phase 5: Provision of interprofessional care for approximately three months based on the agreements made in phase four, ending with an (online) multidisciplinary consultation. The IPC is evaluated during the consultation and its extension should be discussed.

  1. A more detailed description can be found in Supplementary File 2.
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