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Internal Medicine

Training Level

Resident PGY 1


Henry Ford Allegiance Health


Problem Issue: Patients that have frequent use of health care is often complicated by socioeconomic related factors. Process to Improve: Targeted multidisciplinary intervention to coordinate care; done with a Case Conference format. Metric to Change: Implementation of Case Conference. Target of Performance: Decrease rates of healthcare use and hospital re-admission. Analysis of Causes: Patient are increasingly affected by influences surrounding their healthcare. No current process for identifying and following patients who need access to community resources. Improvement Actions: Initiate Case Conferences as a way to identify gaps in patients access to resources. Link the care team by reviewing shared complex patients; communicate challenges and creating a consistent plan of care. Results: Identified owners to the process and created standard work to ensure success in the adaptation of the new process. Next Actions: Monitor readmission rates, and develop targets (as needed) to measure our success. Lessons Learned: Implementing the DMADV framework. Develop and improve the process of measuring success of the project. Providing confidential access to all stakeholders.

Presentation Date


Case Conference: Care Coordination Continuum Task Force