Michigan Center for Clinical Systems Improvement (Mi-CCSI) has been approved by the Michigan Institute for Care Management and Transformation (MICMT) to provide the MICMT Introduction to Team-Based Care course training.
Provider Delivered Care Management and Care Coordination support the concepts of the Chronic Care Model, the Patient Centered Medical Home and the Team-based Care approach. Together, multi-disciplinary team members partner to form the practice care team to; effectively empower patients and their families, engage patients in self-management and health behavior change, positively affect patient self-care practices and decision-making, provide comprehensive assessment and care planning using shared decision making, implement evidence based interventions and advocate for the right care, at the right time and in the right place.
Multi-disciplinary care teams work across all care settings from hospital, to clinic, to home and are well positioned to connect patients, providers and services to assure that care is coordinated, safe and truly patient-centered. They are part of the patient’s medical home care team and work collaboratively to prioritize patients in need of specialized care coordination services.
Team-based roles may include enhanced discharge planning, holistic support and assessment of social determinants of health, improved internal patient transfers and external transfers to other facilities or to home, and knowledge of psychosocial changes that impact patient care options.
Questions? Please contact Amy at firstname.lastname@example.org