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Patient-centered Family-focused, Documentation? Not so much, KIV Team…
Patient-centered
Family-focused
Quality over quantity
Balance
Quantity: Number of patients as whole
Quality care
Measure quality
self check: know we are doing well
Patient-reporter outcomes
Blocked
PCOC/SWAN
Goal Attainment Score
(shared ownership)
Intrinsic values
Pay-it-forward (comms?)
The type of patients
screening
special -> general
stratify
specialities
target service for stable cases
channel to day care
chronic cases
Training
(build capacity)
Educating
referrers
Building up GPs
(but not equipped)
Internal education
Community
Engagement
Pay it forward
Review process
and structure
we
blocked
structure needs fixing
best practices
"intentional"
review cases
input
plans/actions
Technology
VR
Teamwork
Interdisciplinary
Nurse+doctor+MSW+PCA
Ownership(who is the primary)
Who contacts?
Who coordinates?
Who updates?
"Transdisciplinary"
Subject matter experts
Tackling "solo"
Dedicated personnel
Hospital: work closer with them
Care for self/others
Flexible work
Still enjoy the work
Diversity, Equity, and Inclusion
(race, language, sexual orientation)
Practicing awareness of language
Volunteer interpreters
How to engage?
Plan with it in mind
Sensitivity to disadvantaged
Disabled
"shady" past
LGBTQ+
Documentation?
Not so much
KIV
Team-based approach
Triage
Eg. St Jude
team
Longitudanal Assessment
of needs (PLAN)
Culture to understand
and to hold accountable
Evolving care model
PCFF - needs driven
Team based
(transdisciplinary)
Serve more
Care for self and other
1) Measure quality
2) Screening
3) Processes
4) Team and
ownership
5) Flexible work
6) DEI