12/25/2023 0 Comments Innovolt power manager 20 amp![]() The primary care and care management teams at Brigham Health spearheaded this intervention. Our overarching goal was to discern and elucidate patients’ goals and values so this information could be leveraged in the appropriate context as needed. 6 - 8 Earlier high-quality communication about what matters most to patients holds the potential to add value to the care we deliver, primarily by improving patient and family outcomes and possibly also by eliminating some avoidable costs. 2 - 5 Evidence also suggests that appropriately timed serious illness conversations (SICs) with the correct intention (elucidating patient goals and values in the context of shared awareness about an uncertain future with serious illness) could lower costs. Proactive conversations about patients’ goals and values in the context of advancing serious illness can improve health care outcomes, such as anxiety, depression, and bereavement, and may help align the course of medical care with evolving patient preferences. Our goal was to develop a stratified approach that engaged multiple members of the care team in outreach to diverse patients at risk of Covid-19 infection or complications in order to understand their preferences related to potential serious illness. Leveraging a robust care coordination team that had extensive experience with implementation of care management and the Serious Illness Care Program in the primary care setting, 2 we sought to develop and deploy a population health approach to patient outreach regarding serious illness preferences during the Covid-19 pandemic. This goal was in line with broader population health priorities centered on serious illness outreach set by Brigham Health’s parent organization, Mass General Brigham. Additionally, in light of accumulating evidence that the pandemic was having an outsized impact on older and sicker patients, as well as those residing in specific socioeconomically vulnerable communities in Boston, 1 we felt there was an imperative to share information regarding Covid-19 and available resources with the most at-risk populations. ![]() The authors’ experience demonstrates that such a population health approach can facilitate timely and well-accepted outreach regarding serious illness to patients with varied needs and profiles.Īs morbidity and mortality from the Covid-19 pandemic rose in Boston during spring 2020, ensuring that patients’ health care proxies (HCPs) and serious illness wishes were known to care teams emerged as a population health priority at Brigham Health. Simultaneously, nurses, medical students, and social care team members reached out to non-iCMP primary care patients identified as being at high risk of morbidity or mortality from Covid-19 and engaged these patients in conversations regarding health care proxy documentation and social determinants of health needs. Patients enrolled in the Integrated Care Management Program (iCMP) were contacted by their own nurse care coordinator for a serious illness conversation, discussing patients’ goals and values in the context of underlying illness and the threat of Covid-19. The authors engaged a diverse set of team members in outreach regarding serious illness conversations. During the Covid-19 pandemic’s first surge in Boston, Brigham Health sought to ensure that patients’ health care proxies and serious illness wishes were known to care teams.
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