What is Team Care at the Coastal Health Alliance?

By Mike Witte, M.D.
Dani Vincent, RN, approached me this week about a new patient. The man showed up at one of our health centers with a minor injury, which she tended to. He was very appreciative, but while treating him, Dani noticed, in getting his deeper story, that he had some serious issues that were more chronic. She also discovered that he was homeless, and not able to easily find a place to stay. She called Health and Human Services in Point Reyes, and got the social service team activated to help him. That day, one of their staff met him in town to help find him shelter and to get him access to services. Dani alerted me to all this so that one of the doctors in our group would know what was in progress to help this man. She also contacted one of his relatives in another state to alert them to his situation and get more information to be able to help him. She set him up with future appointments with one of our doctors to pursue helping his other problems.
Allan Zephyr, RN and Allison Cole, RN were discussing one of our very complicated patients today. They were sharing updated information regarding her care, as she had just had major orthopedic surgery and was entering a rehab hospital. She wouldn’t be able to come in for her regular visits during this time, and they wanted to consult each other regarding next steps in how to best help her from a distance while she is rehabilitating from her major surgery. They parsed out her various needs in transitioning to home: a hospital bed, in-home caregiver, nutritional needs, in-home physical therapy and occupational therapy, medication adjustments and possible side effects.
Jennifer Dow, RN and Maricela Luna, one of our many great Medical Assistants, spent their entire lunch hour, with the Health Center otherwise closed, sitting with one of our patients who had nearly passed out when she had her blood drawn. They quickly assessed her for safety, and called in a physician to evaluate her. Once they knew she was safe, they stayed with her to emotionally support her through a scary event. When she felt up to going home, fully recovered, she was very grateful for the caring support from Jen and Mari

The general practice of medicine has evolved dramatically over the past generation. Doctors in primary care—GPs, family doctors, internists and pediatricians, are continually inundated with new information and new demands on their time to help their sick patients get well and help their healthy patients stay that way. They are also being asked to screen all patients, young and old, to help prevent many common diseases.
At Coastal Health Alliance we empower each and every staff member to develop skills in listening and communication, as well as to show empathy and sincere interest for our patients’ needs. Our front office and phone team members are likely the first person that a patient will talk with when accessing the health center, and therefore play a vital role in making our patients feel welcome and supported. They set the tone for our interactions in the health center in which all staff members strive to help each patient receive “the kind of care they want, when they want it.”
We have formed four care teams made up of all our staff. Each team has a panel of patients for whom they are the primary contact. At the beginning of each clinic day, the teams each meet for 15 minutes to prepare for all patient visits that day. Beforehand, the RN on each team has identified more complex situations and addressed them to the team. The RNs and MAs (Medical Assistants) partner with the doctors, nurse practitioners and physician assistants to help patients get their lab results, medication refills, and communicate advice to them.
This Team Care concept is in the works with us. We are just now learning this concept and identifying how to best work together as teams. And, at the center of this care is the patient. Our teams have no one leader. Different people rise up to lead different aspects of what we do. But the team would never be complete without each patient being centrally involved in decisions about her or his care. We see our roles as providing expert and appropriate tools to help the central member of our teams, each one of our patients, to reach their goals for good health.

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