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In order to provide effective care coordination for patients, it's absolutely essential that your primary care team be able to communicate and work together seamlessly and intuitively.
Staying on the same page from the beginning makes all the difference in care delivery and the expectations of team members. Everyone has a job to do and role to play.
Here are three tips to empower your care team to deliver excellent experiences from the moment patients walk in the door.
Make time for daily team meetings to discuss each patient before they’re seen. This is a lot more feasible with an advanced primary care approach, because the team is preparing for fewer but more time-rich appointments.
In order to have these conversations, team members need access to health information in digestible forms so they can come to the huddle prepared to contribute. The goal is to uncover potential risks and needs for each patient.
Patients communicate different things to different members of the care team; in the daily huddle, care teams can come together and share their different perspectives, forming a better, more complete picture.
Today, most healthcare delivery follows a similar pattern: primary care providers act as screeners and gatekeepers, referring patients out to specialists for treatment. However, breaking away from that mentality is essential to providing advanced primary care.
The care team needs to approach patient interactions as part of holistic medical care rather than taking a siloed approach similar to specialist care. A patient may have come in to address a certain issue, but that it may not be the only problem they're dealing with. It could be a symptom, or it could be unrelated — but can still be the entry point into a conversation that reveals much more about the patient's health needs.
Lastly, your care team can't be certain when you'll see a patient again, or under what circumstances. Each visit is a valuable opportunity to listen, discuss, make important connections, and practice preventive care. This may include screenings or tests, but it's mostly about empathetic listening and a holistic approach to medical care.
After your patients leave for the day, come together as a care team to discuss the outcomes of each visit and any follow-up that needs to take place. Follow-up is critical to providing well-coordinated, closed-loop healthcare.
Sometimes, that means following up with someone who has had trouble tolerating medications in the past. Other times, it means making sure they connect with a health coach.
The outcome of this post-visit meeting is to get the entire care team on the same page and identify what actions need to be taken and who is responsible for follow-up, whether it’s delivering test results, managing a specialist referral, or procedures that need to be scheduled.
Creating systemic collaboration is simple, but it takes time, communication, and consistency. On a primary care team, starting and finishing the day with planning and follow-up huddles is the first step. Making the most of every patient interaction is an ongoing process of reinforcing empathetic listening, problem solving, and a collaborative approach.
When patients know that someone is watching out for their well-being and managing all the details of their healthcare, they're free to focus on living a healthy, happy life rather than remembering details and worrying about costs. This kind of care will only improve engagement, and improved engagement means better health.
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