"Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs"

This is a great paper to read, it illustrates a model that embraces all the different needs of patients such as medical, psychological, and social.  This model is already being used by different States (CMS) in the structure of the Health Home, which primary goal is to provide comprehensive care coordination to people with multiple chronic conditions, high hospital utilizations (not having an assigned medical home provider) mental health needs, drug and substance abuse, plus social determinants of health such as housing, access to food, employment, etc.  Care coordination is a necessary, not just the right thing to do, unfortunately reimbursement is not yet being taking into account by CMS, which hinders practices to provide comprehensive care coordination services to those that are most needed. However, we know that there are some new initiatives around care coordination with some payment incentives, the Health Home being on of them, which still in the infancy stages, but some progress is being made.



Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs

Connecting Health Care Providers with Patients/Families

For most part, patients feel comfortable with their health care provider. They often keep all the medical appointments, call in for refills, and sometimes will keep an specialist appointment.  However, the gap of communication continues to exist, and patients may not identify their health care provider as the person to go to for all their medical needs. Here is where we talk about care coordinator, they are key individuals to serve as the "go to" person,  a liaison, an advocate, in some cases cultural brokers and mediators. Care coordinators serve the role as medical/mental health services connectors, they link patients with the appropriate health care providers. They also serve the role as community navigators, identifying and connecting patients with resources and services. 

Care coordinators are a vital component of the medical home, they are the glue to an continum expanding model and are the fibers that link all medical, mental health, social services, natural support systems, structural systems, community resources, and the health care system. 

Below is a links for the Health Care Research and Science that has a complete definition and resources for care coordination services. 

www.ahrq.gov/...care/.../coordination/

Care coordination

About the Author 

Helen Dao, MHA

A Public Health Consultant 

www.daoconsultingservices.com

Dao Management Consulting Services, Inc.: PATIENT’S/FAMILY’S CULTURAL AND LINGUISTIC ASSESSM...

Dao Management Consulting Services, Inc.: PATIENT’S/FAMILY’S CULTURAL AND LINGUISTIC ASSESSM...: Here is a great tool that we have developed for health care providers and care managers to use with patients and families during a visit or ...

PATIENT’S/FAMILY’S CULTURAL AND LINGUISTIC ASSESSMENT CARD®

Here is a great tool that we have developed for health care providers and care managers to use with patients and families during a visit or an intake.  We beleive that it important to learn as much as we can about patients/families cultural and linguistic background in order to access and provide effective care and services.

It can be difficult to know and understand the diverse needs of patients and families when cultural and linguistic needs are unknown or misunderstood.  Having insight into the patients’ cultural, ethnic, and linguistic background can help avoid miscommunication and the potential for misdiagnosis or poor adherence to treatment and appointments follow-up.

This tool was designed, as a vehicle to collect pertinent information about the patient/family cultural and linguistic needs.  The tool should be implemented in two stages:

1. The first section is for the patient/family to answer during the intake process.
2. The second session is for the health care provider/care manager to complete post-visit based on his/her observations during visit.

By completing this tool, we hope that the practice will identify its strength and vulnerable areas such as lack of appropriate language services, low level of staff training on cultural and linguistic appropriate services, the need for a cultural broker, and creating a practice environment where there is a two way communication between the provider and patient/family.

Here is the link to our tool, hope you find it useful.

DAO_patientfamilyculturalandlinguisticassessmentcard

About the Author:

Helen Dao, MHA

A Public Health Consultant

www.daoconsultingservices.com

201-448-2046

Dao Management Consulting Services, Inc.: Patient/Family-Centered Medical Home and Care Coor...

Dao Management Consulting Services, Inc.: Patient/Family-Centered Medical Home and Care Coor...: Care coordination is the centered-piece of the patient/family centered medical home model.   On a daily basis primary care...

Patient/Family-Centered Medical Home and Care Coordination

Care coordination is the centered-piece of the patient/family centered medical home model.  On a daily basis primary care providers work hand and hand with care managers to ensure patients have access to appropriate preventive care services, community resources, education, and information about their treatment plan, and to behavioral health services.  Care coordination has become an essential component and a necessary of a practice daily operation, clinical outcomes goals, and organization’s policies changes.  A well-positioned organization will ensure that care coordination is a vehicle of change and a model that can be incorporated at every level of the organization and engages every member.

Below are some key components that we help practices focus on:

• Evaluate strengths and areas for improvement in implementation of care coordination within the medical home model
• Develop are coordination team action plan to improve collaboration and teamwork in the practice
• Focus on proactive, longitudinal care within the patient/family-centered medical home
• Identify and use tools to integrate patient and family input throughout the course of care
• Improve communication and accountability among providers within the medical home model
• Recognize the role of care coordinators working collaboratively to improve patient’s goals
• Explore the nature and dynamics of “care coordination partnerships”
• Identify, understand, and address barriers related to cultural diversity and appropriate language access
• Understand the social and economic determinants of health impacting patients
• Recognize barriers to assessing health-related social service needs
• Develop strategies to address health-related social service needs in the patient/family-centered medical home
• Recognize socio-economic factors impacting development and treatment of disease

h    About the Author:

      Helen Dao, MHA

      Public Health Consultant

      helen@daoconsultingservices.com