Box 3 Key features and core activities of summit A-ICU

1. Transfer of care to the co-located stand-alone team Patients transfer care from existing primary care to the SUMMIT team to encourage coordinated, unified care from a single team. Co-location offers opportunity to facilitate interdisciplinary meetings, as well as informal conversations to enact care plans during non-visit time

2. Comprehensive initial intake The first visit(s) include a 60 min social intake with the Social worker, followed by a 60 min medical intake with provider/care coordinator with open ended questions and focus on patient health goal elicitation and assessing self-efficacy and treatment burden. The visit forms the basis for the patient-centered, goal-based care plan

3. Interdisciplinary team reviews Following intake, subsequent activities and appointments are determined based on patient status, medical and psychosocial complexity. Set time aside for daily huddles provide opportunity to discuss the patients scheduled for the day, and recently hospitalized or discharged patients. Weekly “speed dating” rounds provide opportunity to review existing patients assess whether current interventions are working and revise care plans as necessary

4. Transitions of care coordination/tracking Led by the complex care nurse, and pharmacist, the SUMMIT team developed protocols for coordination of care for hospitalized patients to communicate pertinent information to inpatient care teams, and develop follow up care plans prior to patient discharge

5. Built-in counseling services Led by the social worker but supported by all team members who are trained in motivational interviewing, trauma-informed care, and cognitive behavioral therapy. Social workers provide individualized counseling and leverage existing linkages to mental health prescribers as necessary

6. Navigation of social services Team members assist patients with long term care planning, advanced directives, linkages to community resources such as disability, housing benefits

7. On-demand availability and access to off-hours warm lines A separate SUMMIT team phone number is available for patients and patient caregiver teams to access SUMMIT team members at all hours of the day. SUMMIT physicians cover the phone during off-clinic hours to respond to patient care needs and concerns

Additional activities/flexibility

8. Outreach visits Team members are available to conduct outreach visits for patients on an as needed basis. Visits are used as an opportunity to assess patients outside the clinic, develop rapport and trust, and facilitate and support a health related activity (i.e. Accompaniment to specialist referrals, delivery of medications if temporarily homebound, assistance with access to social services)

9. Pharmacy education/chronic disease medication management For select patients with non-controlled chronic disease conditions (diabetes, hypertension, heart disease), the SUMMIT pharmacist is available for 1 to 1 consultation and medication review and management. The pharmacist is empowered to enact the care plan and titration or tapering of medications

10. In-visit scribing Care coordinators sit in on medical visits with provider and patients and scribe for the provider. This activity promotes unified communication of the care plan between patient, care coordinator, and physician; and allows improved patient experience during face-to-face visits