Coordination of care

Care coordination is a broad term and can have different meanings across healthcare settings. Best practices in care coordination should include a model that establishes a common language, sets expectations, and educates the care team to ensure all members are aligned. The model should consist of clear definitions and criteria for predictive analytics and risk stratification of the patient population. Strong risk stratification provides a method to tailor care to individuals at greater risk. The care coordination model should also include the following:

  • Identification of the interdisciplinary care team, including medical, behavioral, pharmacy, and social team members, to address all health-related individual needs, enabling all members of the care team to work across the continuum.
  • Comprehensive assessment to identify the members' needs and barriers to care.
  • Communication strategies such as rounds, warm handoffs, and connected Electronic Health Records or Electronic Medical Records (EHR/EMR) to allow for early intervention and preventative measures to keep members healthy.
  • Robust monitoring system for follow-up care.
  • Methods to address polypharmacy and indiscriminate use of benzodiazepines and other controlled substances.
  • Ongoing improvement activities to evaluate interventions, monitor quality, and refine predictive analytics and risk stratification methodologies.

Coordination of care resources

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