The team approach to home-based primary care: restructuring care to meet individual, program, and system needs

J Am Geriatr Soc. 2015 Feb;63(2):358-64. doi: 10.1111/jgs.13196. Epub 2015 Jan 30.

Abstract

Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician-led academic home-based primary care practice was restructured into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team-based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.

Keywords: homebound; multidisciplinary care; nurse practitioner; team-based care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Female
  • Home Care Services / organization & administration*
  • Hospitalization
  • Humans
  • Male
  • Patient Care Team / organization & administration*
  • Patient Satisfaction
  • Practice Management, Medical / organization & administration*
  • Primary Health Care / organization & administration*