Care coordination models: Discover what they are and how to build one

Explore the essential components for successfully implementing a care coordination model in healthcare

Care coordination plays a crucial role in healthcare settings by ensuring patients receive timely and efficient care across multiple healthcare providers. Its goals include improving patient outcomes, reducing care gaps, and streamlining care delivery systems.

This way, healthcare organizations can enhance the patient experience and reduce hospital readmissions. Keep reading to understand care coordination models and learn how to build and implement one for your healthcare setting.

What are care coordination models?

Care coordination models are structured approaches that guide the integration of different healthcare providers, ensuring that patients receive well-coordinated care throughout their treatment.

These models aim to improve communication among providers and between providers and patients. Some common examples include:

• Patient-Centered Medical Homes (PCMH): These primary care practices have restructured their facilities and workflows to better manage patients and coordinate care, especially for those with multiple chronic illnesses [1]. This model emphasizes comprehensive primary care facilitated by a team of providers working together to address all of a patient’s healthcare needs [2].
• Community Health Workers (CHW) Model: Community health workers (CHWs) function with local healthcare systems in urban and rural areas, often sharing the same ethnicity, language, and life experiences as the people they assist [3]. In this model, they act as a bridge between healthcare providers and patients, helping patients navigate healthcare systems, especially in underserved communities [3].

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Benefits of care coordination models

Care coordination models offer numerous benefits to both patients and healthcare providers:

• Cost efficiency: Coordinating care helps prevent duplicate services and unnecessary treatments, reducing overall healthcare costs for both patients and organizations.
• Reduced readmissions: Patients have enhanced follow-up care, which helps avoid complications that can lead to readmissions.
• Better management of chronic conditions: Patients with chronic conditions can access a multidisciplinary team that addresses their healthcare needs holistically.
• Enhanced communication: Coordinated communication between various healthcare providers improves the overall quality of care and ensures that patients receive appropriate treatment at the right time.

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Five tips on how to build and implement a care coordination model

Tip #1: Evaluate your current care delivery system.

Identify where care issues exist and, if there is an existing care coordination model, assess its gaps. Consider both the organization’s and patients’ needs, focusing on areas like continuity of care, access to resources, and communication breakdowns.

Tip #2: Assemble a multidisciplinary team

This team should include healthcare professionals from different specialties, such as primary care physicians, nurse practitioners, mental health specialists, and social workers.

The team’s composition may vary based on the specific model, patient demographics, and program goals. It ensures that patients receive comprehensive care. For instance, a care coordination model for managing chronic diseases might require endocrinologists, nutritionists, and health coaches to work collaboratively.

Tip #3: Educate patients

Patients must understand their role in the process, learn about their care plan, and be encouraged to actively manage their health. Rather than solely focusing on their immediate medical condition, care coordination models prioritize their overall well-being by providing education on preventive measures, lifestyle changes, and self-management strategies.

Working with a corporate health and wellness coach can enhance this approach by providing personalized guidance on lifestyle changes and preventive care. Coaches can help patients stay accountable, offer motivation, and tailor wellness plans aligning with their health goals and long-term well-being.

Tip #4: Leverage data and technology

It helps to foster more effective communication and collaboration among healthcare providers. Virtual care platforms and care coordination software can streamline communication across various locations and unify health systems. This results in more cohesive care and better patient outcomes.

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Tip #5: Monitor and reevaluate

Implementing a care coordination model isn’t a one-time task. Monitoring and evaluation are necessary to ensure the model delivers the desired results. By regularly assessing patient outcomes, provider performance, and system efficiency, healthcare organizations can make adjustments to the model as needed.

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How we can help

At WeCare tlc, we develop and optimize care coordination models tailored to your organization’s unique needs. Our onsite and near-site clinics provide comprehensive support, helping employers manage healthcare demands with personalized management services while empowering employees to take charge of their health.

Discover how WeCare tlc can design a care coordination model that aligns with your company’s objectives. Contact us today.

Sources:
1: A needs assessment of health information technology for improving care coordination in three leading patient-centered medical homes | Journal of the American Medical Informatics Association.
2: Defining the PCMH | Agency for Healthcare Research and Quality
3: Role of Community Health Workers | National Heart, Lung and Blood Institute