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Patients deserve better outcomes at lower costs. Grant Makers in Health or GIH reference the “triple aim” as a solution.
The triple aim splits the goal into three definable categories and it’s important to remember that good performance in one does not guarantee the other.
Transforming the healthcare delivery system, with time, will take both local and broad-scale investment and change. Care coordination and communication will be key.
Anyone involved in healthcare may see the need for better systems to be put into place, and many work towards transforming healthcare delivery in several different ways.
Patients are too often admitted to the hospital or given overlapping/duplicated treatments due to poor communication and an emphasis on a payment incentive over quality care. Changing the financial incentives of our healthcare system will mean setting incentives for meaningful and quality care.
Care coordination is geared towards innovative optimization of healthcare delivery. It puts the patients’ needs first and works to organize systems that allow for high-functioning communication among patients, providers, and caregivers. It allows for more data-driven decision-making and targeting of high-need patients.
Care coordinators are an essential component of the Medical Home team. In this section of the Medical Home Portal, new and experienced care coordinators will find information, ideas, and resources to provide optimal care coordination in the Medical Home setting. Because the work of care coordinators varies in different settings, you may find some pieces are more applicable to your job than others. Periodically refer back to this section of the Medical Home Portal to consider expanding aspects of care coordination as you broaden your professional role.
The next step is to implement the care plan. Hopefully while you developed the Working Care Plan, you listed discrete tasks, timeframes to complete these tasks, and names of the people who will carry out these tasks . The care coordinator organizes and assists the family with resources, referrals, and coordination of care with specialty physicians, schools, and other agencies. The care coordinator also assists the primary care provider in tasks necessary to implement the care plan.
The critical components of the working care plan include: A prioritized list of needs, concerns and desired outcomes.
The working care plan is a written framework combining the needs, concerns and desired outcomes of the patient, family and Medical Home team along with the medical treatment plan. These plans range from an organized note written during a visit, to a more detailed plan of care developed during a meeting with the family and Medical Home, to a comprehensive, integrated plan developed by the child and family and a multidisciplinary team. Regardless of how complex the Working Care Plan is, families must be the center of the process in order to accomplish a successful care plan.
The term “Children and Youth with Special Health Care Needs (CYSHCN)” is defined in the Questions section, above. Examples of children and families with multiple needs and services include: Children who are newly diagnosed with special health care needs.
Children and Youth with Special Health Care Needs (CYSHCN), their families, physicians, and community providers all benefit from having a comprehensive needs and strengths assessment. The Medical Home should conduct a comprehensive assessment that includes a biopsychosocial assessment of the child and family as well as input from members of the child’s medical care team. Assessments for care coordination of CYSHCN not only focus on the medical needs but also on the family, psychological, socioeconomic and cultural needs. The assessment phase is vital to the care coordination process as the information obtained becomes the basis for the medical summary and the working care plan.
The purpose is to quickly summarize key information relevant to the child’s current and future health. Written components may include a Medical Summary, a Working Care Plan, and/or an Emergency Treatment Plan. These documents may be shared in print versions as well as electronically.