The Importance of Interdisciplinary Care for Homebound Patients

Date: 08|26|2022

Dr. Paul Chiang, the Home Centered Care Institute’s (HCCI) Senior Medical and Practice Advisor, and Medical Director of Northwestern Medicine HomeCare Physicians in suburban Chicago, finds a team mentality to be essential when it comes to house calls.

“I tell my patients, ‘I am only a doctor,’” Chiang said. “There are many issues that come up when caring for complex patients at home that I need additional professional assistance on. It’s important to have the expertise, insights, and recommendations of others in the management of our patients.”

According to Chiang, interdisciplinary team involvement often begins after an initial house call visit where the provider takes a comprehensive history, and performs a physical exam, medication review, and home walk-through. “The walk-through is when I examine the patient’s home environment and see if there are challenges or barriers in the overall care of a patient, such as food insecurity or an ill-placed rug that potentially could be a fall risk,” Chiang said.

After the visit, the provider creates a care plan. Then, once the care plan is in place, the provider can enlist the assistance of other health providers, such as a social worker or physical therapist to improve the well-being of the patient and caregiver.

The structure of an interdisciplinary home-based primary care team varies from practice to practice. Some practices employ providers, social workers, and medical assistants, while others collaborate with nurses and social workers from a home health agency. Partnering with external providers is also a good way for practices to offer support services until they can build up enough patient volume and revenue to sustain hiring for those roles. Plus, working in an interdisciplinary way helps team members work to the top of their license. Working in this way allows the primary care provider to focus on the patient’s overarching medical needs and ensures that areas like social work, dermatology, occupational therapy, dentistry, and others, are addressed by specialists.

Whatever the arrangement, Chiang said the team should have a periodic huddle, or “touch base.” “When we huddle,” Chiang said, “we discuss our patients and their current problems and challenges, and then get input and perspective from others on the team involved in the management of these patients.”

If formal in-person huddles are not possible, phone calls, secure text messaging, or video conferencing can allow team members to stay connected. “Providers can also print and fax visit notes or instructions to a home health agency so the providers are aware of the patient’s conditions, care plan orders, and any follow-up that is needed,” Chiang said.

As Chiang points out, “Working together in this way allows us to learn from each other so we can deliver the care our patients need.”