Care Coordination
The goal of care coordination is to make the primary care practice the hub of all relevant activity. Care must be coordinated not only within the practice, but between it and community settings, labs, specialists and hospitals. The responsibility of the PCMH is not just to be informed by community providers and resources, but to reach out and connect in meaningful ways with other sources of service and link with them, so that information is communicated appropriately, consistently and without delay.
Key changes for Care Coordination:
- Link patients with community resources to facilitate referrals and respond to social service needs.
- Integrate behavioral health and specialty care into care delivery through co-location or referral agreements.
Visit the Behavioral Health Integration page for more information. - Track and support patients when they obtain services outside the practice.
- Follow-up with patients within a few days of an emergency room visit or hospital discharge.
- Communicate test results and care plans to patients/families.
- See examples of one SNMHI participant's Care Coordination interventions and results.
Care Coordination Resources
Implementation Guides
Care Coordination Executive Summary
Care Coordination: Reducing Care Fragmentation in Primary Care
This Implementation Guide begins with an introduction that defines care coordination and the recommended key changes for safety net practices, including a focus on behavioral health integration. It is followed by Reducing Care Fragmentation, a toolkit that includes a detailed discussion of the four basic elements of effective referral or transition management: assuming accountability for care coordination, providing patient support, developing relationships and agreements with key outside providers, and establishing connectivity that ensures appropriate information transfer. The toolkit also includes a series of case studies and links to specific tools (e.g., job descriptions and staff training curricula).
Webinars
Closing the Loop with Referral Management (February 26, 2013)
Moderator: Ed Wagner, MD, MPH, The MacColl Center for Health Care Innovation
Speaker: Linda Thomas-Hemak, MD, President and CEO, The Wright Center for Graduate Medical Education
Presentation slides
Redesign of the Hospital Discharge: Patient-Centered Care to Improve Safety, Cost and Outcomes (August 14, 2012)
Moderator: Donna Daniel, PhD, Qualis Health
Speaker: Kelly McGrath, MD, Chief Medical Officer, Clearwater Valley Hospital and Clinics (Idaho)
Audio & video program
Presentation slides
Care Coordination in Rural Communities: Preliminary Findings on Strategies Used at 3 SNMHI Sites (July 24, 2012)
Moderator: Nicole Van Borkulo, MEd, Qualis Health
Speaker: Sarah Derrett, MPH, PhD, Sr Research Fellow, Dept. of Preventive & Social Medicine, University of Otago Harkness Fellow, University of Chicago; Katie Gunter, MPH, MSW, Project Manager, University of Chicago
Audio & video program
Presentation slides
Integrating Oral Health and Primary Care (February 23, 2012)
Moderator: Nicole Van Borkulo, MEd, Qualis Health
Speaker: Martin Lieberman, DDS, Dental Director, Neighborcare Health (Seattle, WA)
Audio & video program
Presentation slides
Care Coordination in the PCMH (January 19, 2011)
Moderator: Donna Daniel, PhD, Qualis Health
Speakers: Ed Wagner, MD, MPH, FACP, MacColl Center for Health Care Innovation at the Group Health Research Institute (Seattle, WA); Judith Schaefer, MPH, MacColl Center for Health Care Innovation at the Group Health Research Institute (Seattle, WA); Lindsay Losasso, MPH, Squirrel Hill Health Center (Pittsburgh, PA); Olga McLellan, RN, BSN, CDE, Joseph M. Smith Community Health Center (Waltham, MA)
Audio & video program
Presentation slides