Team-Based Care & Social Determinants of Health (SDoH)

We know what improves health and it does not match how we spend for health.

To be most effective, TEAM-BASED CARE should include Community Based Resources as part of the Care Team.

Comprehensive Care partners with OCHI for Care Management technology designed to integrate Community-Based Organization (CBO) resources and workers into a coordinated Care Team using a single platform.

The Team-based care model relies on clinical guidelines for best practices, and often employs multi-disciplinary practitioners to collaborate with the treating physicians.

  • Psychiatrists/Clinical Psychologists
  • Social Workers/CounselorsüPharmacists
  • Nurses
  • Care Managers/Coaches
  • Physical Therapists

The combined Care Team will be able to use the CCARE Health Care Management technology for 24/7 patient access and engagement.

CCARE HEALTH will work with your organization to identify and fill any clinical staffing gaps for best practices provision of Care Management Services.

Our remote Care Team will operate as a transparent and seamless extension of your Care Team led by the treating physicians.

Best Practices for Cardiovascular Disease Prevention Programs

Using a team-based care model can improve hypertension control.
A collaborative practice agreement between pharmacists and providers can improve patient care.
This strategy can improve blood pressure control at home.
Empower patients to take steps to reduce risks and manage chronic disease.
Lowering costs can eliminate barriers between patients and the medications they need.
Point-of-care prompts support providers in following clinical guidelines.
Engage CHWs as members of the care team in the community.
Pharmacists play an expanding role in patient care and education.

These CDC guidelines describe and summarize scientific evidence behind 8 effective strategies for lowering high blood pressure and cholesterol levels. TEAM-BASED CARE is central to these guidelines.

“Team-based care is a delivery model where patient care needs are addressed as coordinated efforts among multiple health care providers and across settings of care.”

“Well-implemented team-based care has the potential to improve the coordination, efficiency, effectiveness, and value of care, as well as the satisfaction of patients and providers.”

“The central goal of team-based care is to provide the most effective, efficient, and accessible evidence-based care to the patient.”

“Care Team Providers can include health professionals such as physicians, nurses, pharmacists, occupational therapists, social workers… and the intentional inclusion of patients and family members.”

“The success of using virtual care in healthcare delivery has become increasingly defined by the patient experience. Improving patient access to care, avoiding high-cost services, coordinating patient-provider interactions, improving patient satisfaction, and saving patient time and money are regarded as core success metrics.”

“The American Diabetes Association recommends using a team-based approach to optimize care for patients with diabetes. However, primary care clinics often do not have the resources to have inter-professional teams on site. Telemedicine can bring inter-professional team-based care to patients in healthcare practices by utilizing telehealth technology.”