Care Team Integration

Our clients need a range of expertise to get and stay healthy—so in 2016, we launched care teams.

Now, we meet in cross-disciplinary teams around shared panels of clients. Staff communicate more frequently. Providers team-up to implement smarter workflows. As a result, we believe that clients get better care. We've come a long way in this work, but we know there's more to do. Full integration takes careful planning, some experimentation and, simply, time.

This year, we’re taking the next step together: Physical care team integration at 421 Fallsway.

We're beginning to co-locate care team members so that clients go to one place for their care, just like with the Orange (family and pediatrics at 421 Fallway), Jade (Baltimore County), and Magenta (West Baltimore) teams. By starting small, with only one team (the Yellow Team) moving, we'll have time and space to learn from one another and to experiment with new approaches.

Then, we'll come up with a plan to integrate the other three adult care teams at 421 Fallsway: Green, Purple, and Steel.

Resources

for everyone

• Daily huddles
• CAAs on care teams
• Review of Activities—Yellow Team, January-April 
• Where we’ve been—and where we’re going
• FAQ
• Care team listing
• All-staff presentations: January, February, March, April, May, June, July, August
• Empanelment
  • ​How-to Guide
  • Cheat Sheet 
  • Medical Provider FAQ
  • Behavioral Health Provider FAQ
  • Care Team Facilitator FAQ

For Care team providers

• Talking to clients about care teams

for Yellow Team

• Floor plan

Research

• Core Principles & Values of Effective Team-Based Health Care
• A Review and Proposed Standard Framework for Levels of Integrated Healthcare

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