If you are an athlete, you can appreciate the feeling of having a whole team behind you. It is a great comfort to know so many people are there to back you up. At Avera Medical Group we are developing coordinated care models to provide our patients with teams. The goal of a coordinated care model is to help improve patients’ understanding of disease, treatments and the steps needed to become healthier.
A coordinated care team is physician-led and made up of a registered nurse clinical coordinator who works closely with the patient and a coordinating care support specialist who coordinates the different treatments and appointments. Teams may involve social workers, pharmacists and other specialists as needed.
To be part of this program, patients must agree to participate and keep up their end of the deal. They will be asked to handle certain responsibilities such as completing workbooks to help track their progress and to bring those books to all their appointments. This program will be very helpful to those who have multiple health concerns. Being on multiple treatment programs can be difficult to manage. In those situations the coordinated care team will be there to help navigate multiple medications and medical jargon.
The teams will be reaching out to their patients at home and work, allowing for more interaction between patients and health care providers. We want patients to be more actively involved in their care. Patients will have more than one person to turn to with questions and to help run plays. Working with the patients as a team will lead to many more wins.