The SHWC interdisciplinary team is defined more broadly than many health care teams. It includes physicians, nurse practitioners, a social worker, nurses, receptionists, a pharmacist, and a dietician. Ad hoc members include a chaplain, physical therapists, a home health nurse, a behavioral health professional, and a patient information librarian.
Each patient's health status is assessed at the first visit using standardized tools that measure mental status, risk for falls, depression, nutrition, and other health conditions. Medical practice guidelines for chronic pain, falls, diabetes, urinary incontinence, dementia, and osteoarthritis are used.
An electronic medical record houses all of a patient's medical records (from hospitalizations and visits to the clinic) on the same platform. Extension of the electronic medical record into nursing homes and home health/hospice has allowed for improved communication of vital information across care settings. Reports identify patients who go to the emergency room, hospital, or outpatient surgery.
A central element of the SHWC team care approach is hour-long weekly
care conferences. The interdisciplinary team, which includes every
staff person in the clinic, meets to discuss high-risk, complex
patients. “Everybody has their own perspective,” says Kathleen Chinn,
Nurse Practitioner, Senior Health and Wellness Center, PeaceHealth
Medical Group. “The people in the front office know the patients
differently than the nurses and the nurses know the patients
differently than the physicians. Everyone brings something valuable to
the table.”
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