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Telemedicine is a game-changer in healthcare.  It greatly increases options for contact with patients while offering constraints that must be addressed.  The work of enhanced healthcare teams, shown to be necessary for delivering robust care to patients with complex burdens of medical and behavioral illness, must be adapted to the new technology in order to deliver evidence-based care to this important population.

-Dr. Alexander Blount

the Patient

Lucy Roberts is 58 years old.  She struggles with type 2 diabetes, high blood pressure, and anxious depression.  She had a twenty-year history of heavy drinking, but has been able to stay sober for about 12 years.  She had traumatic experiences as a teenager that make it very hard for her to trust people, but she has made important strides in that area in the last few years.  She has been getting her care at the primary care practice for about 14 years.

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Elena Harmon,
the Medical Assistant

 Elena has been working at the practice for 8 years.  During that time, the role of MA has been expanded so that she is a more central team member.  She has gotten extra training in conducting follow-up discussions about patients’ screening results, including beginning an assessment of suicidal or homicidal ideation.  She helps patients formulate their questions for the physician, and often helps patients begin the process of setting health goals.  She routinely gives a summary of her conversation with the patient to the doctor (in front of the patient) when he arrives, so he can review or extend the processes she began.  She is a consistent member of one healthcare team so she can develop long-term relationships with team members and with a panel of patients.


Dr. Valeras,
the Family Physician

Dr. Valeras has led the practice’s transition to more patient-centered care.  This involved creating healthcare teams with consistent membership, sharing leadership in his team with other members, and creating space in the schedule for the team to meet (huddles, discussion of patients, targeted quality improvement projects).  He piloted the practice’s special attention to services for patients with complex health burdens, including the introduction of the Patient-Centered Care Plan.

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Dr. Valeras
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Dr. Burke,
the Behavioral Health Clinician

Dr. Burke was trained as a psychotherapist, but she has transformed her way of working since she came to primary care 13 years ago.  She now focuses on brief, targeted behavioral interventions using Cognitive Behavioral Therapy and Solution Focused Therapy as guiding concepts.  She has been instrumental in teaching other team members to use a strength-based approach, particularly in working with patients with histories of deprivation or trauma.  She provides leadership to other team members on behavioral health issues (mental health, substance use, and health behavior change) just as Dr. Valeras provides leadership on medical issues.

Maria Ruiz,
the Community Health Worker

Maria doesn’t appear in the video, but she is a very important member of the team.  She provides a link between underrepresented groups in the community and the services of the practice.   She grew up in the same public housing complex in which Lucy now lives.  She helps engage patients in care, offers them guidance in accessing the larger medical system, helps connect patients with other community resources, and helps support and educate patients to meet their health goals.

Dr. Burke

Patient-Centered Care Viewing Guide



Patients with complex burdens of illness often need a well-coordinated team of healthcare professionals to maintain or improve their functioning. Providing care to them through telemedicine requires focused efforts toward engaging them in the process, and in adapting the routines of team care to the technology.


A well-functioning team is important for engaging patients with complex health burdens and reducing burnout of both physicians and staff members.


“Complex" patients are identified as such because they bring multiple chronic illnesses plus behavioral health diagnoses, and because they often utilize substantial care resources without gaining a corresponding benefit. Building a partnership between the care team and the patient is especially challenging, but it is necessary to improve the patient’s self-efficacy in maintaining their health. 


Transparent Care

Transparent care has been called for by the Institute of Medicine, by experts in Trauma-Informed Care, and has become law since the passing of the Cures Act which requires that patients have electronic access to the clinical notes about their care.  When professionals adapt their language in notes so they can be useful to patients, this can be the beginning of a culture change in medical settings toward making the patient a partner in the design of their care.


Empowering Care

Empowering care engages patients and promotes self-efficacy by highlighting the patient’s strengths, what they do well, and their past successes in maintaining or improving their health. This focus provides the foundation for their next steps toward their health goals.


Activating Care

Activating care highlights attributes of the patient that make taking steps to maintain or improve their health consistent with their values, and part of who they are. Patients experience team members as actively supporting their efforts to be healthier.


Mutual Care

Partnership with patients requires that each interaction is built on a mutual determination of the directions of care.  Collaborative discussion of the agenda for a doctor visit, and shared decision making about the treatment plan can be part of the care for most patients.   For patients with complex burdens of illness, the additional step of creating a Patient-Centered Care Plan (PCCP) can greatly improve the participation of the patient and the awareness of the team about the patient’s preferences, goals, and life circumstances.  A very brief review of the PCCP before a visit can help each team member work with the patient in ways that increase engagement and activate partnership. 

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