Tuesday, October 7, 2014

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



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