Background: Team-based care has been linked to key outcomes associated with the Quadruple Aim and a key driver of value-based care. With a perfect storm of events taxing our U.S. health system, it is essential to capture and analyze data about teams in real time. Use of the Electronic Health Record (EHR) and machine learning have significant potential to overcome previous barriers including lack of relevance to daily practice, delays in accessing data to improve teamwork, and invisibility of…

The Finding Ease in Caregiving Project lays the foundation for a unique interprofessional collaboration delivered by multiple professions including a musician, case manager, two nurses and a socio-environmental gerontologist. This novel intervention highlights the critical role of interprofessional teams working together to develop multifaceted patient-centered strategies to improve health outcomes. One in ten Americans over age sixty-five has Alzheimer’s Disease or a related…

United States has the highest maternal mortality ratio in the developed world with Black mothers 3-4 times more likely to die in childbirth. A woman’s risk of mortality is associated with patient factors especially presence of chronic conditions compounded by social determinants of health; community-public health factors like access to care, lack of management/care coordination between providers and organizations; provider factors like deficits in pregnancy-specific knowledge and…

The genesis of our Hospital to Home (H2H) Program began at the peak of the COVID-19 pandemic in Texas, due to critical hospital bed shortages. Our teams implemented the project to ensure a timely and safe discharge of our patients from the hospital/SNF/ER settings to the patient’s home. The H2H Program expedited patient throughput and increased hospital bed availability in three specific market locations with assigned Hospitalists. A specific referral process was developed for early…