Implementation of Interprofessional Case Conferencing to Address Complex Biopsychosocial Needs

Abstract

Problem: A community assessment of Southwest Baltimore found a population with medical, economic, and social needs. The population needs were directly impacted by its residents’ social determinants of health in this community, including homelessness, poverty, unemployment and unmet medical needs. Professional departments within community center work independently without a structured collaborative process or shared documentation despite mutual patients with multiple complex biopsychosocial needs. Purpose: The purpose of the quality improvement project was to implement and evaluate the effectiveness of interprofessional case conferencing. Methods: Department leaders from case management, health and wellness, financial advisement, workforce development, and community outreach were trained on the concepts of the social determinants of health, care coordination, and case conferencing. The evaluation of complex biopsychosocial needs was incorporated into each department’s workflows. Patients (neighbors) who were found to require intervention from multiple departments were referred to the case conferencing team. This interprofessional team met weekly to discuss shared neighbors, provide updates, and set goals, all of which was documented on a single shared template accessible to all. Pertinent data were collected and analyzed including: total neighbors referred, number of neighbors discussed at conferences, attendance of professionals at conferences, and number of individual goals met. Results: By the end of the 15-week implementation period, a total of 108 neighbors were referred with 225 needs identified. A total of 89 discussions were had about 34 neighbors. At the conclusion, 12% (n=12) of neighbors met their individual goals and 24% (n=25) were still actively working with departments. Twenty eight percent (n=29) had been lost to follow-up, and 36% (n=37) were never reached via the contact information provided. By midpoint, there was 100%+ staff attendance at weekly case conferences. Conclusions: Interprofessional case conferencing is an effective method for interdepartmental collaboration. The method and procedure used in the implementation of this project can be individualized and applied to multiple settings and organizations.