On Demand: A Foundation for Integrating Community-Based Care Into Health Systems-Presentation Slides

Presentation Slides

Pdf Summary

The document outlines insights and strategies from MedAxiom for advancing cardiovascular care in 2025. It emphasizes the integration of clinical guidelines and social determinants of health (SDOH) to improve patient outcomes. The care strategies must be adaptable, evidence-based, and tailored to diverse patient populations, incorporating SDOH into care planning to reduce health disparities.<br /><br />The document promotes multidisciplinary, team-based care as essential for delivering patient-centered cardiovascular care. It underscores the importance of defining roles within the care team, extending collaboration to include patients, families, and local organizations for a personalized, context-aware care approach. This method aims to enhance care quality, continuity, and patient engagement.<br /><br />In physical care delivery, the document advocates for a mix of traditional and innovative settings to optimize care access, including hospitals, clinics, mobile units, retail clinics, and virtual hubs, prioritizing accessibility and convenience.<br /><br />Data-driven care is highlighted as pivotal, advocating for advanced technologies like remote patient monitoring to enable targeted interventions and continuous care improvement. Disease-specific and episode-based protocols customize treatment plans to individual patient conditions, fostering improved outcomes and higher standards in cardiovascular care.<br /><br />Assessment tools are proposed for evaluating and refining care delivery, encouraging robust data usage to ground clinical decisions. The document stresses a multidisciplinary model for better patient management and economic alignment to balance clinical excellence with financial responsibility.<br /><br />Pilot programs, like developing an Atrial Fibrillation (AF) Center of Excellence, are discussed, supporting key stakeholders in ideation and care objectives definition. It outlines target patient populations, appropriate care sites, necessary services, and performance metrics. The implementation strategy includes developing a clinical and business proforma, project management, and communication plans.

Keywords

cardiovascular care

clinical guidelines

social determinants of health

multidisciplinary care

patient-centered

remote patient monitoring

data-driven care

Atrial Fibrillation Center

health disparities

care access