Care coordination is the featured topic of the latest issue of the U.S. Agency for Healthcare Research and Quality's (AHRQ) Health Care Innovations Exchange, which is a program AHRQ initiated to speed the development and adoption of innovations in healthcare delivery. Coordinating care between healthcare settings is vital to avoid duplicated efforts, conflicting care plans and medication mismanagement, including overuse, underuse and misuse of medicines. Case studies of providers' care coordination efforts include:
- The Children's Hospitals and Clinics of Minnesota uses a Limited English Proficiency Patient Family Advocate as a permanent part of its hematology/oncology care team. This advocate provides traditional interpretation services, as well as helping patients and families as they move across the continuum of care. The program cut the length of the average interpreter encounter in half and generated high levels of patient and provider satisfaction.
- The University of New Mexico Health Sciences Center's Care One program provides intensive case management and care coordination services to uninsured, high-cost,medically complex patients. Each enrolled patient is assigned to a physician-led team that includes a social worker and behavioral health specialist. This team helps the patient navigate the care continuum, as well as accessing financial assistance and appropriate community resources. The program significantly reduced inpatient admissions and emergency department visits, as well as boosting patient satisfaction.
- In the Bypassing the Blues program at seven Pittsburgh-area hospitals, nurse care managers screen patients after cardiac bypass surgery for symptoms of depression. Patients who exhibit meaningful symptoms receive ongoing telephone-based support over an eight-month period. The nurses use a collaborative care model to educate patients about depression, teach them self-management skills, and explore and promote recommended treatment options. Nurses discuss cases weekly with a psychiatrist, psychologist and internist, as well as routinely communicating with the primary-care physician. The program improved mental and physical health status in both men and women, and men experienced a decline in hospital readmissions.
To learn about the results of these and other care coordination case studies and to find useful tools:
- visit the AHRQ Health Care Innovations Exchange