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Effective coordination of care by a multidisciplinary team is a key facet of caring for high-risk patients in the patient centered medical home. However, no existing IT tools adequately facilitate the intra-team task assignment and information sharing that are key to effective care coordination.
At the Jen Center for Primary Care, we are creating an electronic "coordination dashboard" that describes a high-risk patient’s most important background information, their main problem areas (e.g. diabetes, homelessness), and key goals/tasks in these areas. We are using the dashboard as a centerpiece for huddles in which teams discuss high-risk patients’ goals, and team members are assigned tasks related to these goals. In between huddles, team members remotely update the dashboard with their progress.
In early tests, use of the dashboard put team members “on the same page," and increased satisfaction with intra-team task assignment, intra-team referrals and accessing patient information.