To help advance quality primary care in the region, Health First funded the establishment of team-based care in North Country HealthCare’s family residency program. The goal: Teach new physicians and their colleagues a coordinated approach to patient care and improve health outcomes.
Team-based care is health providers working collaboratively with patients and caregivers to accomplish shared goals and achieve coordinated, quality care. Such care works to minimize the occurrence and severity of disease, offer better disease management, limit emergency department visits, and lower healthcare costs.
A Health First grant enabled the residency clinic to explore team-care models, determine what worked, and implement new care approaches that benefit patients and their families.
Residents learned the approaches and value of team care during the grant project. They implemented daily huddles to discuss patient care and utilized a new tool to identify patient gaps and streamline clinic visits. With these innovations, patients experienced more focused and efficient care.
As part of the program, the residency team established monthly interdisciplinary case conferencing to address the complex care needs of HIV/AIDS patients.
“We get together and do a deep dive into the patient – their medical history, their care, what resources they have, what’s holding their progress back, all of it,” explains Dr. Sarah Coles, the residency director. “In the end, we come together with an agenda and a care plan specific to that patient.”
One resident made this encouraging observation: “Participating in case conferencing has benefited both me and my patient. As a primary care physician, I work hard to ensure that my patients receive high-quality care. Sometimes, though, we are limited by time, costs, and competing priorities. Case conferencing has helped to bridge that gap and improve the care patients receive.”
A federally qualified health center, North Country focuses on people who often can’t afford care at 11 locations across northern Arizona. The health center’s family care residency program is the only one in the region.
While this grant project was confined to the residency clinic and the 7,000 patients seen during the grant period, the impact will grow in two ways.
First, with a newfound understanding of the power of collaborative medicine, graduating residents will take the holistic, team-care approach to their practices impacting future patients.
Additionally, North Country HealthCare plans to expand the model throughout the organization, giving all its patients the benefit of quality, team-based primary care.
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