Smart Transitions of Care: Fostering the Team that a Recovering Patient Needs

June 9, 2021

The care and recovery journey for acutely ill patients has always benefited from expert clinical teams. Communication, support, and leadership all improve timely reaction to the changing clinical situations in recovery. Technology plus integrated clinical teams can provide excellent support for patients recovering from a hospital stay, if we break down traditional silos and organize a team to work together for the patient. On this webinar, Dr. Tricia Baird, VP of Care Coordination at Spectrum Health, talks about real challenges and shares proactive solutions related to wrapping a coordinated team around patients with changing conditions and complex needs.

Learning Objectives:

• Understand the series of recovery behaviors that patients need to complete in transition from inpatient care to baseline health
• Recognize the signals patients give about whole-person needs – clinical + behavioral + social health
• Build an incremental program launch, able to refine the team structure and needs based on evolving understanding of the population being served
• Articulate differences in clinical care to support Fee For Service contracts versus Value Based contracts
• List the unique challenges for patients without a primary medical home or a primary team that shifts due to acute illness