Clinical Care Team

The healthcare industry in our country is going through a fundamental change in the way in which it approaches the provision of care to patients. It is moving from a disease focused, non-integrated approach to a more integrated understanding of healthcare as a multifaceted, value-based premise. We used to think of a successful provider as one who treated a great number of individuals, while today we think of success in a more qualitative rather than quantitative way. It matters less how many, and more how well those individuals feel and fare. This new approach sees the patient as more than just their physical body, its problems and its needs, but as a whole person, who’s socioeconomic, mental and behavioral characteristics greatly affect their overall health and wellbeing. Thus, in order to provide truly beneficial care, we must take all these factors of every person’s life into consideration when we seek to design a care plan that will be effective and suitable to their needs. Accomplishing this necessitates a cross-functional team of care-takers such as the primary care provider, specialists (cardiologists, nutritionist, psychologists, chiropractors, and so on), family members who might be care givers or drivers, etc., and in the center of them all, the patient themselves, who’s input, education, awareness and involvement in their own care is key!

Many people are dealing with mental or behavioral issues such as depression, Alzheimer’s disease, dementia, alcoholism, or other addiction, which may prevent them from successfully following care plans and medication regimens. In addition, socioeconomic factors such as lack of access to transportation, unemployment, insufficient access to grocery stores, might add yet another layer of complication and difficulty. Addressing each of these issues in isolation will do very little to improve the patient’s overall health, as changing the care plan to address one issue might cause negative impact on another. To achieve a successful result, we must create coordinated communication between a team of providers, nurses, social workers, pharmacists, psychiatrists, community resources, and family members, to communicate the different needs, and come up with solutions that address the full complexity of an individual’s needs.

This new integrated cross-functional team approach is called Advanced Care Management. Its goals are to care for people as whole, multifaceted human beings, improve the quality of care, and reduce the overall costs of healthcare nationwide, by making it more efficient, integrated and focused. It is good for us as individuals, and it is good for us as a nation.