At Bellin Health System, James Jerzak, MD, and team use team meetings not only to improve workflows, but also to discuss high-risk patients. The team has meetings every Friday at noon for one hour. During the meeting, they engage the extended care team which includes representatives from pharmacy, behavioral health and case management, the health coach, and the RN Care Coordinator—either in person or by phone. To plan for the upcoming week, they review the schedule to discuss any patients who would benefit from the services of the extended care team.
Dr. Jerzak's team refers to a particular patient story as an example of how they have successfully used team meetings to work together towards providing better patient care:
The day before the team care pilot began, Dr. Jerzak saw a patient with severe COPD, no insurance, multiple medications that she didn't understand, and numerous hospital admissions in the previous two months. During this visit, Dr. Jerzak told her that his team would be starting new team meetings with an extended care team the following week. He believed these meetings could help address her care needs so she could improve her health.
This patient's medical issues were the first problem the team tackled as a group. Within a week of the first team meeting, the case manager helped the patient obtain insurance and the pharmacist met with the patient to figure out what medications she had and what she should be taking. The diabetes educator initiated a program to help with her uncontrolled diabetes, the health coach met with her regarding smoking cessation, and the RN Care Coordinator made the first of several home visits. The patient even called the RN Care Coordinator at home on Christmas with issues, which helped the patient avoid a possible hospitalization. The patient was also seen by behavioral health once the extended care team members were engaged. This all began with a team meeting to get buy-in from all members of the practice to support this patient and improve her care.
Dr. Jerzak asks, “How could one doctor possibly do all of that, without this team of support?”
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