9 AUGUST - 2022DEVELOPING UNDERSTANDING BETWEEN PATIENTS AND THEIR CARE TEAMS IS FUNDAMENTAL TO SUPPORTING THE PATIENT AND ACHIEVING THE BEST OUTCOMESnot traditionally supported under fee-for-service reimbursement.This includes supporting our patients with transportation services and access to various community resources. BUILDING RELATIONSHIPS BASED ON TRUSTIndividuals with significant needs can benefit greatly from an integrated care team that is inclusive of primary care providers, physicians and advanced practice clinicians, behavioral health providers, rehabilitation specialists, nurses, and community health workers. Culture and approach to care are equally important; developing understanding between patients and their care teams is fundamental to supporting the patient and achieving providers, rehabilitation specialists, nurses, and community health workers. Culture and approach to care are equally important; developing understanding between patients and their care teams is fundamental to supporting the patient and achieving the best outcomes. In addition to frequent check-ins with the patient and/or caregivers, the integrated care team maintains a close communication regarding shared patients through daily huddles and team meetings. EMPOWERING THROUGH DIGNITY OF RISKWhen responding to the clinical needs of a patient, it is critical to also consider social, emotional, and intellectual needs. Importantly, care teams must respect patients' choices and follow the concept of dignity of risk. This concept means that all legally competent adults have the right to make their own choices about their care, even if those choices may lead to poor health outcomes. This approach builds and maintains trust and is especially critical for patients who have experienced trauma or are living with a mental health diagnosis. This concept may be difficult for providers who may be troubled by what they consider to be "bad decisions."MEETING PATIENTS WHERE THEY ARETo keep the patient at the center of treatment planning, care teams must meet the patient where they are most comfortable. About 60 percent of CCA Primary Care patients receive care primarily in their homes. When caring for individuals with complex needs in an ambulatory setting, it is important that physical locations are equipped to provide disability-competent care, with features such as Hoyer lifts and wheelchair scales, which are intended to support comprehensive examinations. It is important to spend quality time with each patient during their visit, to ensure they feel valued and to keep them engaged in their care.Assuring patients have access to appropriate communication devices or interpreter services is also important. DEVELOPING PARTNERSHIPS THAT SERVE PATIENTS' NEEDSWe often work in a partnership with home health agencies and incorporate their family and personal-care-supports, as appropriate. In certain cases, we collaborate closely with our State's Departments of Mental Health, Developmental Services, and other external agencies. Additionally, through CCA, our patients have access to palliative care as well as community paramedics for urgent or after-hours needs. As we are part of the same organization, we can ensure the right level of service based on patient need. CCA Primary Care is also expanding the services at our ambulatory locations to include Engagement Centers for our patients to improve quality of care and health outcomes through acute care diversion, peer support, behavioral health and addiction treatment, and social engagement in a flexible, non-judgmental, and welcoming environment.The research is clear that primary care is essential to advance population health and equitable outcomes, particularly for the most vulnerable and complex among us: seniors and people with disabilities. Their optimal care requires a comprehensive team, advanced systems, and, most importantly, a trusting relationship with the patient. With this strong foundation, healthcare providers can break down barriers to care and improve overall health and well-being for their patients.
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