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Box 2 Summit A-ICU intervention description and team structure

From: The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale

Team structure
 Care coordinator—the patient’s primary point of contact, the care coordinator assists with patient follow up, acts as scribe for physician face-to-face visits, conducts outreach activities with the goal of enhancing rapport building
 Team manager—the team manager coordinates patient and team schedules, interfaces with clinic operations and administration, conducts outreach, and leads team activities, including organizing trainings, and process improvement cycles
 Physician—General internist with additional board certification in addiction who provides front line care to patients including acute and chronic disease management, advanced care planning, medication management, and coordination of care with specialists
 Social worker—a licensed clinical social worker embedded in the team who meets with the patients on Day 1 to elicit social vulnerabilities and provide counseling + case management support to patients as needed
 Complex care nurse—a nurse that provides medical triage services, transitional care planning, and assists patients with health education activities as well as outreach (accompanying patients to specialty appointments)
 Pharmacist—the pharmacist works with patients and team members to assist with medication reconciliation, transitions of care, and chronic disease medication management for patients (diabetes, heart disease) with the goal of reducing medication treatment burden