Effective care coordination can help reduce hospital readmission and emergency department (ED) use and helps to ensure that patients receive comprehensive and seamless care.
Improve patient care outcomes using key strategies, such as:
- Teamwork and collaboration: Establish a multidisciplinary team that includes doctors, nurses, social workers and other health care professionals to work together on patient care.
- Communication: Regularly communicate with patients and their families to understand their needs and preferences.
- Care management: Develop individualized care plans that address the specific needs of each patient.
- Health information technology: Utilize electronic health records (EHRs) and other technology tools to track patient information, coordinate care and facilitate communication among providers.
- Patient-centered medical home: Implement a model of care that is patient-centered, comprehensive, coordinated and accessible.
- Transitions of care: Help patients transition smoothly between different care settings, such as from hospital to home.
- Self-management support: Empower patients to take an active role in managing their health by providing education, resources and support.
- Linking to community resources: Connect patients with community resources and services that can support their health and well-being.
- Monitoring and follow-up: Continuously monitor patient progress and follow up to address any changes in their condition or care needs.
Implementing best practice strategies can lead to improved patient outcomes, higher patient satisfaction and more efficient use of health care resources.
Care coordination and team-based care involves individualized care plans tailored to each patient’s specific needs, coupled with smooth transitions between care settings, such as from hospital to home, reduces the risk of hospital readmissions and prevents unnecessary ED visits.
Transitions of care
Care management
Teamwork and collaboration
Additional resources
Patient engagement and communication focuses on facilitating open communication with patients and their families, empowering them with the education and resources needed for effective self-management. By implementing a patient-centered care model, this approach ensures that care is coordinated, accessible and tailored to each patient’s unique needs.
Communication
Self-management support
Patient-centered care
Additional resources
Community and resource linkages involve connecting patients with local services that support their health and well-being, while integrating these resources into personalized care plans for comprehensive care management.