Role of Primary Care Organziation

The majority of formalized health care delivery takes place in primary care settings. Health TAPESTRY uses interprofessional teams to more effectively meet the needs of our aging population through the combined use of technology, system navigation, trained community volunteers, and partnerships among primary care and community agencies.

Primary Care Organizations work to streamline care coordination pathways for their clients through the Health TAPESTRY approach. They will develop in-clinic workflow plans and determine the key activities the interprofessional team will need to carry out in order to best assist Health TAPESTRY clients.

During the implementation of Health TAPESTRY, the interprofessional team will triage Health TAPESTRY reports, taking action as required based on the information provided by their clients about their own health needs and goals.

Health TAPESTRY Project Team

To ensure the successful implementation of Health TAPESTRY, a project team consisting of a few different roles will be required within the Primary Care Organization. This team will work closely with the Health TAPESTRY Central Team and will work to ensure the program is well-integrated into the clinic workflow. It is recommended that these roles be defined early in the process so that staff and clinicians are aware of who to access for questions and feedback throughout the implementation. Below is a description of these roles and responsibilities. Keep in mind that they may be adopted by one person, or the responsibilities can be spread across multiple individuals.

Practice Model Champion:

The Practice Model Champion is someone who understands the value of Health TAPESTRY and leads staff and clinicians during the implementation of the program. Some of the functions of the Practice Model Champion may include:

  • Engaging staff and clinicians in the planning and implementation of Health TAPESTRY within the clinic
  • Identifying training and development needs for team members
  • Preparing and sending communications to the team outlining the Health TAPESTRY approach, changes to workflow, and providing ongoing project updates
  • Determining a process for identifying and selecting eligible clients
  • Establishing a huddle group and determining how TAP-Reports will be shared for review
  • Putting mechanisms in place for connecting clients with community resources
  • Describing and documenting best practices and how the team is functioning and communicating

Operation Support:

The Operation Support can be one or more people who support the day-to-day operations of Health TAPESTRY within the site. The Huddle Lead provides important operation support.
Some of the functions of the Huddle Lead may include:

  • Coordinating a regular time and space for the huddle to meet
  • Inviting a clients physician to provide context notes on TAP-Reports as needed
  • Reviewing and organizing TAP-Reports in preparation for huddle meetings
  • Inviting other allied health professionals not ordinarily part of the huddle group to attend when needed
  • Ensuring the huddle’s plan of care is document in the Electronic Medical Record (EMR)
  • Be a representative of the of the huddle when interacting with clinic management and community partners
  • Lead huddle planning, agenda setting, and guide discussions

Administrative Support:

One or more members of the project team will be responsible for:

  • Working with the site’s IT staff to ensure Health TAPESTRY technologies are in place
  • Participating in the recruitment of eligible clients
  • Uploading completed TAP-Reports to the Electronic Medical Record (EMR)

Evaluation Data Collection:

One or more members of the project team will be responsible for:

  • Ensuring that data required for evaluation and reporting is collected appropriately (e.g., completing the chart review process, organizing time and space for a healthcare provider focus group)
  • Liaising with the Health TAPESTRY Program Manager throughout implementation and evaluation

Learn about project management from a Primary Care Organization perspective

Or learn more about interprofessional health care teams.