The Delaware Center for Health Innovation (DCHI) www.dehealthinnovation.org is considering multiple approaches on how to provide coordinated care across the State so that all residents receive convenient, effective, and appropriate healthcare throughout the Delaware healthcare system.
Organizing care involves aligning personnel and other resources needed for all aspects of patient care and the exchange of information among the healthcare professionals responsible for the different components of care. To achieve care coordination tailored to Delaware’s needs and circumstances, DCHI has developed twelve common processes.
According to DCHI in the January 2016 report “Care Coordination as an Extension of Primary Care”, the first step is to identify high-risk patients which requires developing and maintaining a registry of high-risk patients likely to benefit from care coordination.
The second step is to enroll the patient in the care coordination program. This requires communicating with high-risk patients to tell them about the practice’s approach to care coordination and how the patient and their family can work together.
The third step is to identify the patient’s health and psychosocial goals by identifying treatment goals in the context of the patient’s lifestyle and preferences. At this point, it is necessary to create the care plan with the patient.
It is very important to maintain a multidisciplinary team capable of working smoothly together which means bringing together all relevant providers, organizations, and individuals who will provide care for the patient.
The team needs to coordinate medication for their patients and must start with a careful documentation of the patient’s medication history. The team must assess the medication component of the care plan on a regular basis.
The team needs to ensure involvement of specialists into the patient’s care. It is also important to ensure access to behavioral health and provide population health support resources for those patients who need this type of help.
When a patient needs to transition from one place to another, a care transition plan has to be developed to ensure continuous care along with community support. The first step is to identify patients who are expected to undergo a care transition and then work with relevant providers and organizations on how to effectively accomplish this goal
It is very important for the team to hold meetings on a regular basis to review complicated cases. These discussions can involve topics such as acute admissions, referrals of patients to relevant services, and changes in care plans.
Since the family can play an important role in the care of the patient, discussions need to be held on regular basis with the family so that the family will stay motivated and engaged in the care of the patient.
The last step is to review the performance and process of care coordination within the team. This means that regular performance review sessions need to be held with primary care practices and the team so that care coordination for patients can continuously be improved.
Go to www.dehealthinnovation.org/Health-Innovation/Publications to view the report.