Advanced Medical Teams: Improving Patient Health, Care Coordination
The triple aim of healthcare reform has been a major focus in healthcare since the Patient Protection and Affordable Care Act passed in 2010. Hospitals and health systems across the country are beginning to take responsibility for the health of their patient population and look for ways to improve care quality and patient outcomes while lowering costs.
Des Moines-based Iowa Health System was one of the many systems seeking to work toward the triple aim. “We were looking to identify ways to strengthen the relationship between patients and…providers,” explains Monique Reese, ARNP, vice president of clinical services and chief clinical officer of Iowa Health Home Care. From there, Iowa Health System found its solution in advanced medical teams.
The system launched its first advanced medical team pilots in Fort Dodge and Des Moines in June 2012. The pilot programs have since spread to reach six of the system’s regions.
IHS uses data to determine which patients — usually those with chronic illnesses — could benefit from care by an advanced medical team. “We built a trigger list, based on the number of chronic diseases, medications and hospitalizations, and used…electronic health records to drive identification of patients who would benefit from the program,” says Ms. Reese.
From there, there are two main important aspects that make AMTs successful.
Care navigators. Physicians work with care navigators — nurses with an expertise in community-based care — to make the foundation of an AMT. Specialists and other experts, like physical and occupational therapists and social workers, can be brought in on a patient-by-patient basis to work with the AMT when needed.
via Becker’s Hospital Review | continue reading