Essential Elements of Home-Based Primary Care - Virtual Workshop-Recording Day 1 Part 1

Video Transcription

Video Summary

Summary 1:<br />The workshop participants expressed their goals and desires for improving scheduling, coordination, mental health care, and procedures for home visits in geriatric care. They also wanted to enhance efficiency, productivity, chronic care management, billing optimization, and partnerships between healthcare entities. The video features Dr. Chang discussing the principles of home-based primary care, including the importance of clinical leadership, scheduling, care coordination, and patient education. He introduces the four M's (what matters most, mentation, mobility, and medications) as a framework for holistic care. Dr. Chang also discusses financial aspects, efficient documentation, and the resources offered by HCCI for improving knowledge and skills in home-based care.<br /><br />Summary 2:<br />The Transitional Care Management (TCM) model focuses on comprehensive planning and follow-up for high-risk older adults transitioning from hospital to home. It involves a nurse-led multidisciplinary team and addresses communication, collaboration, continuity, and service gaps. The TCM model aims to save costs and improve care quality by reducing hospital readmissions. It starts with an assessment upon admission, provides continuous support during hospital stay, and continues care in the community. This model ensures a smooth transition and appropriate care for patients.<br /><br />Summary 3:<br />Patients with multiple health conditions require a comprehensive and coordinated approach to their care. This includes developing care plans, coordinating with other healthcare providers, and advocating for the patient's needs. Communication and collaboration with the patient and their caregivers are crucial, along with initiating advanced care planning discussions. Prognostication is challenging, but understanding clinical trajectories informs discussions. Providing patient-centered and tailored care is essential.<br /><br />Summary 4:<br />Managing acute and urgent care in home-based primary care requires a well-coordinated system for urgent appointments, triaging urgent calls, and mobilizing resources when necessary. Relationships and partnerships with hospitals and specialty providers are vital for timely referrals and continuity of care. Having a safety plan in place for patients at risk for mental health crises is crucial. Being proactive, organized, and prepared helps provide effective acute and urgent care in home-based primary care.

Keywords

workshop participants

improving scheduling

coordination

mental health care

procedures for home visits

efficiency

productivity

chronic care management

billing optimization

partnerships

Dr. Chang

home-based primary care

clinical leadership

scheduling

care coordination