A home-based primary care team’s success depends in large part on holding an effective and in-person weekly interdisciplinary team meeting. All team members are present to review status of new patients, hospitalized patients, unstable patients, deaths, and several other special categories of high-risk patients. The team meeting list is built by getting patient names from all staff members, and the final list is compiled by the office nurse. Other attendees at the weekly team meeting are representatives from pharmacy, mental health, and a partner skilled home health agency. See Table 2.2 for a sample template of the weekly team meeting. As reimbursement policies change to reward coordination and value, we envision this template being used to document coordination of care time and to justify billing for case management and coordination time.

A robust electronic health record (EHR) and a practice management database are essential tools. This means that all clinicians work on one mobile EHR, where they view data from other sectors of health system (e.g., hospital, home care agencies). Where possible, a practice can also link to local health-care integrated advanced information management systems to track patients across settings (e.g., Chesapeake Regional Information System for Our Patients, or CRISP).