Milestone 1: Care Coordination
Establish internal infrastructure to coordinate care
The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.”
Care coordination is a patient- and family-centered, assessment-driven, team-based activity designed to meet the needs of patients and their families or care givers. Care coordination addresses interrelated medical, social, developmental, behavioral, educational, and financial needs in order to achieve the best possible health and wellness outcomes.
Establishing the internal structure to a primary care practice is the first step to achieving effective care coordination. This internal structure should include establishing formal roles for staff members in support of care coordination and care management in the practice. Practices also should establish processes for managing care coordination activities such as helping patients choose specialists and obtain medical tests when necessary, tracking referrals and test results, promoting smooth care transitions between levels of care, or managing medication reconciliation and shared medical records. Proper care coordination should allow for seamless transitions across the health care continuum in an effort to improve outcomes and reduce errors and redundancies.
The Care Coordinator Handbook provides an overview and a step by step outline to support a Care Coordinator, providing the building blocks for skills training, using Milestone-focused lessons and resources. It also includes key contacts for Anthem’s Clinical Delivery Transformation team, glossary of commonly used terminology, and quick links to frequently used reference documents.
A guide to care management for patients with chronic conditions, limited functional status, or psychosocial needs. This toolkit can help improve an existing care management program or launch a new one.
This sample policy and protocol document comes from a Colorado clinic that has adopted the patient-centered medical home model. It could serve as a template for other practices that want to formalize their care coordination processes.
This sample job description outlines the responsibilities of a practice’s care coordinator.
The Institute for Healthcare Improvement (IHI) provides this white paper that outlines ways to better coordinate care for patients with multiple health and social needs, and reviews the way some organizations have successfully approached care coordination.
This link connects you to a toolkit that includes a comprehensive set of resources for providers adopting coordinated care principles. It outlines a model for care coordination, key changes that set the stage for improved coordination, and examples of how care coordination can improve patient care.
This Continuity of Care Guide (CCG), developed by the HIMSS Continuity of Care Task Force, will help ambulatory care practices optimize Health Information Technology (HIT) and Electronic Health Records (EHR) capabilities to support the continuity of care for patients. The CCG will help your primary care practice develop a foundation of basic care planning for patient transitions of care and hand-offs with specialists and other providers.
This Patient-Centered Primary Care Collaborative (PCPCC) paper defines care coordination, discusses its significance as part of a patient-centered medical home, and describes six practices’ experiences adopting formal care coordination processes.
This Agency for Healthcare Research and Quality (AHRQ) white paper offers a primer on care coordination in the context of the entire health care continuum, from primary care to specialty and ancillary health care – also known as the medical neighborhood.
This introduction to care coordination carefully defines the idea and explores the “essential elements” of successful care coordination. It also explores the role care coordination could play in a patient-centered medical home. Copyright © 2010 National Quality Forum.
Illustration developed by HealthTeamWorks portraying the “Planned Care Visit”, its various foundational components and how they relate to each other.
A review of 14 care management programs focusing on the "super high risk" population--high utilization, high complex patients with a focus on Medicaid. Authored by T. Bodenheimer with an attempt to provide guidance in designing better ways to care for high risk, hard to reach patients
A guide for facilitating patient understanding of discharge instructions with in depth discussions on health literacy focused on ambulatory and inpatient facilities.