Patient Health Care Assist and Support Services, Integrated Case Management, and Complexity Assessment Grids

Abstract

The practice of medicine is much more complicated than in the day of the “old fashioned” house call. Providing respectful patient-centered care remains at the heart of clinician assessments and treatments. However, with the introduction of the Patient Protection and Affordable Care Act (ACA), there is now also an expectation that physicians and other treating clinicians, e.g., clinical nurse specialists, physician assistants, non-physician behavioral health (BH) professionals, will optimize clinical outcomes and reduce costs in the populations of patients for whom they and their group are responsible. Thus, the face-to-face encounter is only one of several components of an increasingly complicated care delivery process. In addition to completing a patient evaluation and providing appropriate treatment, physicians are being asked to improve their communication and collaboration with others involved in the patient’s care, to use health resources efficiently, and to do so in a way that maximizes and documents long-term clinical and functional improvement for the population as a whole, not just the individual patient (McClellan et al., Health Aff., 29(5):982–90, 2009; Epstein et al., Health Aff., 33(1):95–102, 2014). In the USA, often these goals are carried out through integrated clinician and health administrative networks, called Accountable Care Organizations (ACOs).

“Remember teamwork begins by building trust. And the only way to do that is to overcome our need for invulnerability.”

—Patrick Lencioni

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