Community-based palliative care teams often serve patients disproportionately affected by poverty, housing instability, food insecurity, behavioral health conditions, and substance use disorder. Teams must efficiently address these complex social needs. Much of this is time consuming work, requiring specific expertise but not necessarily a license or clinical degree. Expanding the interdisciplinary team to include traditional health workers with experience in housing case management, benefits access, and community resource navigation allows nurses and social workers to work at the top of their licenses, focusing on the conventional palliative care interventions of symptom management, care coordination, and advance care planning. In this webinar, learn how the Advanced Illness Care Team at Housecall Providers in Portland, Oregon added a Care and Outreach Specialist to their team (which serves an urban Medicaid population) and how a value-based payment model supports this work.

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