J6 – “Care Beyond Our Walls“: A Relationship-Based Team Approach in a Geriatric Primary Care Setting During the COVID-19 Pandemic

Summary

The objective of this session is to share outcomes from effective team-based practices that particularly benefit older adults with complex combinations of medical, functional, social, and psychiatric factors that often cannot be fully addressed with fast-paced outpatient visits. The help attendees identify ways they can collaborate with other team members as well as patients to address complex issues, particularly in the era of COVID-19.

At Iora Health, the structure of in-office visits and definition of care team member roles allow for deeper relationships with patients and understanding of their needs. Behavioral health staff, nurses, medical providers, team nurses, and health coaches work together via multiple collaborative efforts to identify patients with complex social needs, medical conditions, and behavioral health concerns and then address them in a patient-centered, team-based manner. Using several approaches to risk stratification, team members focus on patients at highest risk of hospitalization or increased morbidity and mortality. At regular intervals, team members develop a care plan to address social determinants of health, and provide the necessary level of medical and behavioral health intervention. Focus on advanced care planning and clarifying patient wishes for medical decision-making and end-of-life care helps care teams honor patient values and wishes, particularly in transitions between outpatient, hospital, and institutional settings.

In the session, presenters will review team-based processes that have been effective, and then work through case vignettes as small groups with discussion as a larger group to learn to apply a patient-centered, team-based lens to stratifying patient subpopulations, identifying social determinants of health, and planning team-based collaborative follow-up.