The one innovative health care delivery model that incorporates an interdisciplinary care delivery team is the Medical/Health homes delivery model. In this system, the patient has “one” primary care giver that coordinates ALL the care whether it may be needed for a specialist or as simple as a nutritional consult for preventative care and needed education. The team of professionals will focus on chronic condition management, to reduce need for visits to specialist and/or emergency rooms (ANA, 2010).
In California, I found that the Health Homes Program serves eligible individuals with multiple chronic conditions that may benefit from management and coordination of their chronic illness. Health Homes provide six core services:
Comprehensive care management Care coordination (physical health, behavioral health, community-based long-term support, and services Health promotion Comprehensive transitional care
Individual and family support
Referral to community and social support services
Health Homes also include the use of health information technology and Health information exchange, to link services, as appropriate (DHCS, n.d.).
American Nurses Association. (2010). New Care Delivery Models in Health System Reform: Opportunities for Nurses & their Patients.
Retrieved from http://nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/Issue-Briefs/Care-Delivery-Models.pdf California Department of Health Care Services. (n.d.).
Health Homes program; Health Home for Patients with Complex Needs (HHPCN). Retrieved from http://www.dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx