Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs. But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams.
Health coaching can play an especially important role for patients with complex needs, who may struggle to manage multiple conditions, multiple providers, and services outside the health system.
A home-based palliative care program using an interdisciplinary care team reduces hospital costs and unnecessary health care utilization for Medicare Advantage beneficiaries.