Interprofessional Healthcare Team Meeting (IPE)

Summary

The video features Ral Kar, medical director of a clinic, discussing the interprofessional collaborative approach for treating patients with multiple chronic diseases. The clinic's transdisciplinary team, including medical professionals, social workers, and health promoters, focuses on holistic care, addressing medical, educational, and socioeconomic barriers. The team discusses a patient's care plan, highlighting their collaborative efforts to navigate complex healthcare needs and connect patients to community resources.

Takeaways

• 🏥 The clinic specializes in caring for unfunded patients with multiple chronic diseases who frequently use hospital or emergency services.
• 👥 Care is provided through a transdisciplinary team model that includes a provider, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist.
• 🤝 The team operates with a flattened hierarchy, emphasizing collaboration and equal input from all members, regardless of their professional role.
• 📋 The team's approach is patient-centered, focusing on education, health literacy, and addressing socioeconomic barriers to care.
• 🏠 The team conducts home visits, which are crucial for understanding patients' lifestyles and providing personalized care.
• 📝 The clinical pharmacist plays a vital role in consulting on medication management across all teams.
• 👩‍⚕️ The advanced practice registered nurse provides comprehensive care, including physical exams, diagnostics interpretation, and patient education.
• 👩‍💼 The medical social worker addresses biosocial concerns and barriers, such as family dynamics, finances, and mental health, that impact patients' health.
• 🌟 The health promoter or community health worker establishes trust with patients and serves as a liaison between health services and the community.
• 🍽️ The dietitian, with a focus on diabetes education, works with patients to understand their dietary needs and lifestyle, often conducting home visits for better rapport.
• 📆 The team coordinates care by reconciling medication lists, managing appointments, and ensuring patients have access to necessary resources like Meals on Wheels.

Q & A

What is the primary focus of the clinic described in the script?

The clinic focuses on the care of unfunded patients with multiple chronic diseases who are high utilizers of hospital or Emergency Department Services.

How does the health care delivery model differ in this clinic from traditional settings?

In this clinic, care is delivered through a transdisciplinary team model that removes hierarchy, emphasizing collaboration and equal importance of all team members' voices.

What roles do the team members play in the patient's care plan?

Team members include a provider, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist, each contributing unique skills to address medical, educational, socioeconomic, and community resource needs of the patients.

What is the significance of the patient-centered approach mentioned in the script?

The patient-centered approach involves the patient as part of the care team, considering their unique needs and circumstances to formulate realistic care plans and improve outcomes.

How does the advanced practice registered nurse contribute to the team?

The advanced practice registered nurse provides comprehensive care, including physical examination, diagnostics interpretation, prescribing, patient education, care coordination, and communication with other providers.

What specific challenges does Mr. John Smith face as described in the case conference?

Mr. John Smith faces challenges such as an upcoming change in housing, safety concerns due to leaving the stove on, psychiatric symptoms possibly indicating medication issues, and visual hallucinations leading to an emergency department visit.

What is the role of the medical social worker in addressing Mr. Smith's situation?

The medical social worker assists Mr. Smith in addressing biosocial concerns and barriers, such as family relationships, finances, housing, transportation, and mental health, which may hinder his health.

How does the health promoter or community health worker contribute to Mr. Smith's care?

The health promoter establishes trusting relationships with patients, serves as a liaison between health and social services, facilitates access to services, and improves the quality and cultural competence of service delivery.

What is the significance of the dietitian's role in the team, particularly for Mr. Smith?

The dietitian provides specialized care for patients with conditions like diabetes, hypertension, and other dietary needs, offering home visits for a better understanding of the patient's lifestyle and to tailor care accordingly.

What steps are being taken to address Mr. Smith's immediate needs and future sustainability?

The team is planning to increase their involvement with Mr. Smith by providing wraparound care, connecting him with resources like Meals on Wheels, assisting with medication management, and exploring housing opportunities to ensure his immediate needs are met and a more sustainable long-term plan is in place.