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MULTIDISCIPLINARY CARE PLANS: ROAD MAP TO IMPROVING CARE
Sarah A. Cloud, MSW, LICSW, Director of Social Work
Beth Israel Deaconess Hospital-Plymouth
Introduction/Problem
Multidisciplinary care plans provide a systematic approach to meeting an
individual patient’s complex needs by:
o Creating institutional memory across numerous providers
o Summarizing recurrent presentations and related testing
o Identifying existing clinical, behavioral, and social services
o Recommending strategies to promote safe, high-quality care
Aim/Goal
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Provide a snap shot of the patient’s complexity
Provide guidance on next steps to care for the patient
Reduce unnecessary hospital admissions
Reduce readmissions and ED visits
The Team
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Sarah Cloud, MSW, LICSW, Director of Social Work
Pedro Bonilla, MD, Medical Director Outpatient & Emergency Psychiatry
Alejandro Mendoza, MD, Chairman, Department of Psychiatry
Amanda Ortengren, DO, Hospitalist
Kim Scheub, MD, Emergency Medicine
Elizabeth Charron, RN, BSN, Clinical Nurse Manager
Donna Sawyer, APRNBC, Emergency Department
Colleen Slowey-Morelli, MSW, LICSW, Emergency Department
Jennifer Meech, RN BSN, ACM, ED Case Management
Jessica Jordan, MSW, LICSW, Med Surge
Brendan Davidson, BA, Aftercare Specialist
The Interventions
o Patients are nominated by care team members based on complexity or
identified based on utilization pattern.
o Cases are then determined to be medical or social services based on primary
driver of utilization.
o Care Plan development is assigned to a primary author based on type of plan
and familiarity with the case.
o Input is sought from internal and external care team members, including the
patient and family.
o Draft plan is presented to multidisciplinary team for review, recommendation
and approval.
o Plan is updated based on feedback, entered into EMR and shared with patient
and providers.
o Plan is updated as new information becomes available
.
Results/Progress to Date
For more information, contact:
Sarah A. Cloud, MSW, LICSW, Director of Social Work (774)454-1201
�MULTIDISCIPLINARY CARE PLANS: ROAD MAP TO IMPROVING CARE
Sarah A. Cloud, MSW, LICSW, Director of Social Work
Beth Israel Deaconess Hospital-Plymouth
More Results/Progress to Date
Social Services Driven Plan
Social Services
Driven Plan =
ED visits
Effect of Care Plan Implementation on Emergency Department Visits
Medical Driven
Plan =
Admissions
Lessons Learned
o Engage the patient and capture who he/she is as a person, not just as a patient.
o Identify the primary driver of utilization as the basis of the plan - Medical or Social
Services.
o Identify strategies and interventions by discipline and role on the care team.
o Keep the plan short (1-2 pages).
Next Steps
o Expand upon the practice of inviting patients in to develop the plan when not in crisis.
o Continued training across all members of the care team and community treatment
providers.
o Enhance technology to support easy identification of cases with a care plan on record
Effect of Care Plan Implementation on Hospital Admissions
For more information, contact:
Sarah A. Cloud, MSW, LICSW, Director of Social Work (774)454-1201
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Sarah A. Cloud (<a href="mailto:scloud@bidplymouth.org">scloud@bidplymouth.org</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Social Work
Psychiatry
Emergency Medicine
Project Team
Sarah Cloud
Pedro Bonilla
Alejandro Mendoza
Amanda Ortengren
Kim Scheub
Elizabeth Charron
Donna Sawyer
Colleen Slowey-Morelli
Jennifer Meech
Jessica Jordan
Brendan Davidson
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BID-Plymouth
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Multidisciplinary Care Plans: Road Map to Improving Care
Date
A point or period of time associated with an event in the lifecycle of the resource
2018
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Patient and Family-Centeredness
Safety