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The high-quality, supportive care provided at UW Medicine is often complex. Our care teams work together with the patient to address health concerns and environmental challenges to find unique solutions tailored for each patient. Azmera Telahun, MD, senior director of Operations in Long-Term Care at Harborview Medical Center, says his team is able to do this work more effectively because of Mission Forward. Pointing to a philosophical shift created by the initiative that’s encouraged more communication between internal teams as well as their external partners, Telahun says this close coordination streamlines processes and reduces barriers to improve patient outcomes.

Managing complex patient care

Meet Dorothy Moore (name changed), a senior patient at Harborview Medical Center who regularly required complex care treatment. Moore had paraplegia, cardiac conditions and a history of substance use — and was living on her own in an apartment. She routinely needed care in the emergency department with injuries from falling.

After multiple admissions, Telahun and his colleagues on Moore’s care team suggested a long-term care facility would be the best option for Moore’s continued health. When she refused, they encouraged her to accept private in-home nursing visits. But there was a problem: Nursing staff would come during the day, find Moore had fallen again, and bring her back to the hospital for treatment.

The care team brought together their internal resources and external long-term care facility resources to figure out how to best help Moore.

Care team collaboration

Since this cycle was dangerous for Moore’s health, her care teams started meeting weekly with external partners specifically to discuss Moore’s case, trying to find the best solution.

But even the best plans hit roadblocks. Telahun’s team came up with several plans to move Moore into an adult family home that was a good fit for Moore’s needs. It took multiple tries, but eventually, they succeeded in finding a well-suited adult family home.

Telahun says the work Mission Forward has been doing to improve processes and strengthen internal and external relationships is making it easier, faster and more effective to collaborate and deliver better results for patients like Moore.

“This particular resolution would have been unachievable without the changes Mission Forward is creating,” says Telahun. “It gives us a roadmap for the next complicated patient case.”