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A “Behind-The-Scenes” Look At Interprofessional Care Coordination: How Person-Centered Care In Safety-Net Health System Complex Care Clinics Produce Better Outcomes, E. Marshall Brooks, Jodi M. Winship, Anton J. Kuzel

Family Medicine and Population Health Publications

Introduction: While the effectiveness of team-based care and wrap-around services for high utilizers is clear, how complex care clinics deliver effective, person-centered care to these vulnerable populations is not well understood. This paper describes how interactions among interprofessional team members enabled individualized, rapid responses to the complex needs of vulnerable patients at the Virginia Commonwealth University Health System’s Complex Care Clinic.

Methods: Researchers attended twenty weekly care coordination meetings, audio-recorded the proceedings, and wrote brief observational field notes. Researchers also qualitatively interviewed ten clinic team members. Emergent coding based on grounded theory and a consensus process were used to identify …