List the resources (strategic partners) that are needed to meet individual healthcare needs.
Primary Care physicians
Outpatient clinics
Specialty care
... [Show More] providers
Women's Health (preventive care, Ob/Gyn services)
Therapists (e.g., physical, occupation, mental health)
Pharmaceutical support (traditional and specialty pharmacies)
Social workers
Define health literacy
the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
What is the goal for care coordination?
Quadruple Aim:
Improved Physician Experiance
Improved Patient Outcomes
Lower Cost of Care
Imrpoved Patinet Experience
AIMS Model
Patient engagement
Assessment and care plan development
Case management
Ongoing care as needed
AIMS engage
The engagement phase allows the care coordinator the opportunity to interact with the patient and their family, ensure that their questions are answered, and to provide guidance and resources that will help navigate patients through their care plan. Part of engagement involves:
Validating a patient's concerns
Reinforcing the role of the coordinator as a helper/resource
Giving information to address immediate concerns
AIMS assesment and care plan development/case management
The assessment and care plan development phase allow the coordinator to “identify social and environmental factors that may affect medical plan adherence, health care services utilization, and health care outcomes. The assessment process collects information that is helpful for interpreting the completed assessment and using that information to develop a comprehensive care plan that will address the patient’s medical and non-medical challenges.
The case management phase is all about ensuring that the patient stays on track and has the support and he/she needs. Under this model, case management includes
Monitoring goal progress
Offering support
Modifying the care plan as necessary to align with the patient’s changing needs
What is the role of the care coordinator?
Using resource partnerships to not to just connect patients with the key services and levels of care necessary to achieve their healthcare goals, but also to help patients understand why these services are important.
Identify the goals of the ACO's
To improve patient outcomes through coordination of care measures and services that improve a patient's quality of life.
Identify and define clinical-community linkages.
Resources that "help to connect health care providers, community organizations, and public health agencies so they can improve patients' access to preventive and chronic care services".
Discuss how health information technologies are used in a variety of care coordination activities.
With the help of IT:
Accurate and complete information about a patient's health, so providers can give the best possible care, whether during a routine visit or a medical emergency
The ability to better coordinate the care given, which is especially important if a patient has a serious medical condition
A way to securely share information with patients and their family caregivers over the internet, for patients who opt for this convenience; this means patients and their families can more fully take part in decisions about their healthcare
Information to help diagnose health problems sooner, reduce medical errors, and provide safer care at lower costs
What are case management models?
Use clinical reasoning to examine a patient's personal and medical history, so the team can pool resources and different clinical perspectives to make both independent and shared decisions regarding each patient's care.
What are the four steps the AIMS Model encompasses?
1) Patient engagement
2) Assessment and care plan development
3) Case management
4) Ongoing care as needed
What kind of coordination does the Wraparound Care Model provide? For whom?
Youth with complex behavioral needs.
Broker Case Model
Helps clients identify their needs and broker supportive services in one or two contacts.
Clinical Case Management Model
In a clinical case management model, a clinical care provider serves as the case manager. Frequently, the case manager is a counselor or therapist. This model recognizes that many clients face barriers to services that reach beyond simple questions of access.
Strengths-Based Clinical Case Management Model
focuses on empowering clients and their families. Case management and clinical services focus on creating client opportunities for growth, education, and skill development.
Involves outreach, clinical services, advocacy, and robust coordination between case managers and clients
What is the PCMH Medical Neighborhood Collaborative Care Model?
Patient-Centered Medical Home (PCMH). That medical home may then interact with a "neighborhood" of community resources, including a team of outpatient caregivers, specialists, hospitals, mental/behavioral health resources, and non-medical community resources.
What is the greatest challenge of care coordination and case management?
The fragmented nature of care transitioning, in which patients and providers may not always have the same information [Show Less]