Change Concepts

• Link patients with community resources to facilitate referrals and respond to social service needs.
• Provide care management services for high risk patients.
• Integrate behavioral health and specialty care into care delivery through co-location or referral protocols.
• Track and support patients when they obtain services outside the practice.
• Follow-up with patients within a few days of an emergency room visit or hospital discharge.
• Communicate test results and care plans to patients/families.

The goal of the Care Coordination Change Concept is to make the primary care practice the hub of all relevant activity. Care must be coordinated not only within the practice, but between it and community settings, labs, specialists and hospitals. The responsibility of the PCMH is not just to be informed by community providers and resources, but to reach out and connect in meaningful ways with other sources of service and link with them, so that information is communicated appropriately, consistently and without delay.

There are a variety of ways to ensure coordination of care, from co-location with the practice to protocols to standardize referrals. This work is especially challenging in safety net settings where simply finding specialists who will see uninsured patients is difficult, but we feel that improvements in coordination have the opportunity to allow primary care to play a fundamental role in improving outcomes and reducing costs.

• Care Coordination Implementation Guide (April 2011)
  The complexity of modern medicine demands specialization, and high quality healthcare must assure that patients receive care from those people and institutions best trained and equipped to provide a service. Many safety net practices have valuable assets that if organized well can potentially assure effective care coordination. This implementation guide summarizes identified and studied best-practices and provides tangible and practical tools to help practices design and implement effective care coordination programs.
   Care Coordination: Reducing Care Fragmentation in Primary Care

• Care Coordination in the PCMH (January 19, 2011)
  Moderator: Donna Daniel, PhD, Qualis Health
  Speakers: Ed Wagner, MD, MPH, FACP, MacColl Institute for Healthcare Innovation, Group Health Research Institute (Seattle, WA); Judith Schaefer, MPH, MacColl Institute for Healthcare Innovation, Group Health Research Institute (Seattle, WA); Lindsay Losasso, MPH, Squirrel Hill Health Center (Pittsburgh, PA); Olga McLellan, RN, BSN, CDE, Joseph M. Smith Community Health Center (Waltham, MA)
   Audio & video program   Printable slides
  
  
• Integration of Behavioral Health Services Into the Medical Home (November 17, 2010)
  Moderator: Sharon Eloranta, MD, Qualis Health
  Speakers: Barbara Mauer, MSW, CMC, MCPP Healthcare Consulting (Seattle, WA); Lori Abrams Berry, MPH, MSW, Lynn Community Health Center (Lynn, MA); Mark Alexakos, MD, MPP, Lynn Community Health Center (Lynn, MA)
   Audio & video program     Printable slides