Given the multiple tracks that healthcare can take, from inpatient to outpatient and even to community settings, there is a need for care coordination and management of the transition between providers and all settings of care. Unfortunately, this coordination is often episodic or overlooked, and it tends to be organized around a specialty, not primary care. Further, transitions frequently occur with no point person held accountable for coordination.
According to the Agency for Healthcare Research and Quality (AHRQ), “Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. The main goal of care coordination is to meet patients' needs and preferences in the delivery of high-quality, high-value health care. This means that the patient's needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care.”
Care coordination has been identified as an important way to improve how the healthcare system works for patients, especially in terms of improved efficiency and safety. Most importantly, care coordination applied in a targeted way has the potential for improved outcomes for patients, providers, and payers.
Coordinated care is being implemented throughout the care continuum. You may ask, ‘What does a patient care coordinator do?” Here are some detting-specific examples from the New England Journal of Medicine of patient care coordination and how it can strengthen care:
It’s easy to understand why care coordination could make a big different in how one interests with the healthcare system. Here are a few examples that demonstrate the potential impact:
A previous HealthStream blog post about patient care coordination shared that nurses can change this culture of single-setting handoff by communicating: “Yes, you’re here today, but my colleagues have given me a better picture of where you are in your transition. Because of our time together and my commitment to your care coordination and managing your transition, I now have a better appreciation of where you’re going and who’s going to be taking care of you there.” Under the old paradigm, the message might have been, “This completes your visit today, and thanks for coming. Goodbye.” We now emphasize that the registered nurse is now invested in what’s happening to that person when they’re out of sight. This represents a major change in the way we think about how we provide care.
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