Health care organizations are successfully using case conferences or huddles — gathering members of a care team to discuss a plan of action for a patient — to improve care coordination. This webinar will focus on two successful examples.

At the Veterans Affairs (VA) Greater Los Angeles Health Care System, care teams use a huddle system to help deliver care to homeless veterans. A patient meets with a medical provider, a nurse, a clerk, and a social worker for an initial visit, and with a subset of that team for subsequent visits. At the end of every visit, the entire care team gathers in the exam room with the patient, and the social worker leads a conversation about next steps for both the care team members and the patient. Follow-up tasks, such as scheduling appointments, sending appointment reminders, and monitoring lab tests, are entered into a case management log, where they can be tracked over time.

West County Health Centers worked with the design firm IDEO to develop a case conference format, during which the care team brainstorms creative, patient-focused approaches to care. For example, to discuss a homeless man with unstable schizophrenia and a worsening medical condition that was causing frequent admissions, the assembled team included law enforcement personnel, a representative from county mental health outreach, and hospital staff. The collaboration resulted in a coordinated, patient-centered engagement strategy. The patient is now receiving regular care and is being treated as an outpatient.

Learn how these organizations are using huddles and conferences to help care for patients with complex needs. Hear from:

• Jason Cunningham, DO, medical director, West County Health Centers
• Lisa Penny, MSW, MPA, social worker, Homeless Patient Aligned Care Team (HPACT), VA Greater Los Angeles Health Care System

A recording of the webinar and the presentation slides are available below.