PACT ICU Model: Interprofessional Case Conferences for High-Risk/High-Need Patients

Area of Science:

• Interprofessional Education and Practice
• Chronic Disease Management
• Healthcare Systems Research

Background:

• High-risk patients with chronic conditions often have unmet care needs.
• Traditional care models may not adequately address complex, long-term health issues.
• Effective chronic care requires coordinated efforts across different healthcare professionals.

Purpose of the Study:

• To describe the development of proactive, team-based, interprofessional care plans.
• To address the unmet chronic care needs of high-risk patient populations.
• To evaluate the impact of an interprofessional team approach on chronic care delivery.

Main Methods:

• Formation of interprofessional teams including physicians, nurse practitioners, faculty, and clinic staff.
• Development of proactive, collaborative care plans tailored to individual patient needs.
• Focus on addressing specific unmet chronic care requirements within a medical center setting.

Main Results:

• Successful implementation of team-based care planning for high-risk patients.
• Identification and proactive management of previously unmet chronic care needs.
• Enhanced collaboration and communication among diverse healthcare professionals.

Conclusions:

• Team-based, interprofessional care planning is effective in addressing unmet chronic care needs.
• Proactive strategies developed by interprofessional teams can improve care for high-risk patients.
• This model demonstrates a viable approach to enhancing chronic disease management within healthcare settings.