Safer and More Effective Care

We work hard to meet our client’s needs and preferences in the delivery of high-quality, high-value health care. Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants to achieve safer and more effective care. This means that the patient’s needs and preferences are understood and communicated at the right time to the right people. This information is then used to provide safe, appropriate, and effective care to the patient.

Who Needs Care Coordination?
Clients and families with multiple needs and those that require multiple services, providers and resources are usually a good place to start. Examples of clients and families with multiple needs and services include:

  • Clients who are newly diagnosed.
  • Families who recently have moved into the state or to a different area of the state.
  • A client with a progressive condition that requires multiple interventions, hospitalizations.
  • Families with multiple agencies involved in the care of their loved one.
  • Families with limited financial resources.
  • A caregiver/family member who is developmentally delayed, has a severe physical or mental condition or a demonstrated lack of knowledge and skill needed to care for their loved one.
  • A client who has been abused or neglected.
  • Families who request assistance coordinating their loved one’s care.

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What are the benefits of having a designated care coordinator?

  • Promotes coordination of specialty and ancillary services by having a designated person in the practice for specialists, hospitals and home health agencies to call.
  • Maximizes the opportunity to get to know the families and provides the opportunity for someone in the practice to become an “expert” in community resources and government programs.
  • Provides the opportunity to learn from families and to pass along what has been learned to other families within the practice.

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What are some examples of day-to-day activities a care coordinator performs?

  • Answering phone calls from families, addressing their needs, seeking information and solutions to problems.
  • Handling prescription refills, coordinating home care services and medical equipment and supplies.
  • Coordinating coverage with insurance and/or Medicaid. Assist with obtaining prior authorization for services, equipment and supplies.
  • Assessing needs, developing and implementing the plan of care and evaluating effectiveness of interventions and other needs.
  • Assisting families and providing tools (binders, forms, care plans) to help with organizing and tracking medical information about their loved one.
  • Providing referrals and resources.
  • Helping coordinate school programs. Attending and providing input for Individual Education Plans (IEP) meetings.
  • Advocating for families.
  • Conducting home visits when needed.
  • Helping with transition issues.
  • Linking families with other families for support.
  • Providing education.

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The Care Coordination Process

Activities performed by a care coordinator are based upon a comprehensive assessment that includes a psychosocial assessment of the client and family. Identification of needs is the first step in this process. We use an assessment tool which will assist in gathering the information you will need to develop a plan of care. After identifying the needs, a plan is developed with the family, and goals and outcomes are discussed. The care coordinator will then clarify with the family which action steps will be addressed. The plan is implemented and actions are taken to work towards the desired outcomes. Identified service providers and programs all work towards fulfilling the needs of the family. The care coordinator organizes and assists the family with resources, referrals, coordination of care with specialty physicians, schools and other agencies. Periodic evaluations are regularly conducted to identify if there are any new needs.

Caring home healthcare nurse conducts medical consultation with senior woman at her home or nursing home.
Care Coordination
health care - senior woman and man with doctor