Document Type


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Journal/Book/Conference Title

International Journal of Integrated Care




2: 5

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Funded in part by the VCU Libraries Open Access Publishing Fund.

Date of Submission

August 2020


Introduction: While the effectiveness of team-based care and wrap-around services for high utilizers is clear, how complex care clinics deliver effective, person-centered care to these vulnerable populations is not well understood. This paper describes how interactions among interprofessional team members enabled individualized, rapid responses to the complex needs of vulnerable patients at the Virginia Commonwealth University Health System’s Complex Care Clinic.

Methods: Researchers attended twenty weekly care coordination meetings, audio-recorded the proceedings, and wrote brief observational field notes. Researchers also qualitatively interviewed ten clinic team members. Emergent coding based on grounded theory and a consensus process were used to identify and describe key themes.

Results: Analysis resulted in three themes that evidence the structures, processes, and interactions which contributed to the ability to provide person-centred care: team-based communication strategies, interprofessional problem-solving, and personalized patient engagement efforts.

Conclusion: Our study suggests that in care coordination meetings team members were able to strategize, brainstorm, and reflect on how to better care for patients. Specifically, flexible team leadership opened an inter-disciplinary communicative space to foster conversations, which revealed connections between the physical, and socio-emotional components of patients’ lives and hidden factors undermining progress, while proactive strategies prevented patient’s rapid deterioration and unnecessary use of inappropriate health services.


© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See

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VCU Family Medicine and Population Health Publications