TransforMED’s Care Coordination Workbook

The ongoing relationship between the patient and the provider is a cornerstone of primary care.

Item #: 8268

Submit a Review

Need Help?

Non Member Price $99.00

Member Price $59.00
(Save 40%)

Add to Cart

The ongoing relationship between the patient and the provider is a cornerstone of primary care. The healthcare system oftentimes can be a confusing tangle of complicated interactions for patients.

The PCMH model encourages practices to guide patients beyond the practice setting. This can be done through cooperative alliances with essential healthcare services that offer a complete range of needs for a given patient population.

Care coordination involves developing structured relationships with individuals and facilities outside of the primary care setting that are necessary to provide comprehensive care. A need for care beyond the scope of the primary care office occurs frequently, and it is important to include this care in the overall management of the patient.

Care coordination expands the definition of team to include all providers, locations and resources necessary to meet the patient’s healthcare needs. This extended care team can include specialists, hospital facilities, home health facilities, long-term care facilities, durable medical equipment vendors, public health entities, pharmacists, social workers, psychologists, physical therapists and any other healthcare entity that affects the patient’s healthcare.

Effective care coordination provides for an understanding of each team member’s role and responsibility at the time of the patient interaction and a clearly defined information flow between team members. Each team member has accurate current information for every patient at each encounter.

Topics covered in this book include:

Obstacles to effective care coordination
The care coordination process
Coordination with hospitals, emergency rooms, and urgent care facilities
Coordination of care provided by specialist physicians
Planning for effective care coordination
Implementation
Care coordinator role
And more than 20 templates are included for your immediate use

2010, 82 pp., ISBN 978-1-56829-383-7

PCMH Care Coordination Workbook

Table of Contents

Chapter 1 - INTRODUCTION

Explanation of the TransforMED Model
Description of Individual Modules
Patient-centered Care
Access to Care and Information
Practice-based Services
Care Management
Care Coordination
Practice-based Team Care
Quality and Safety
Health Information Technology
Practice Management
Interconnectivity of the Modules
Transformational Principles
Leadership
Teamwork
Communication
Change Management
Relationship-building
The Transformational Journey

Chapter 2 - CARE COORDINATION

Care Coordination
Trends of Complexity in Healthcare Needs
Obstacles to Effective Care Coordination
Patient Obstacles
Physician/Practice Obstacles
Facility Obstacles
Payer Obstacles
Community Obstacles
Summary

Chapter 3 - WORKBOOK

Care Coordination Process
Patient Population
Panel size
Age and gender demographics
Chronic disease demographics
High-risk–high-acuity demographics
Significant risk factors
Coordination with Hospitals, Emergency Rooms, and Urgent Care FacilitiesFacilities used by your patients
What and how information is shared
Office workflow
Coordination of Care Provided by Specialist Physicians
Identify frequently used specialist physicians
What and how information is shared
Office workflow
Planning for Effective Care Coordination
Engaging a Team
Reaching Consensus
Defining Appropriate Information
Determining an Efficient Mechanism for Sharing Information
Evaluating Office Workflow
Implementation
Communicating and Negotiating Needs
Developing and Facilitating an Agreement
Follow-up
Additional Opportunities for Coordination of Information
Care Coordinator Role

Appendix A - TEMPLATES

Appendix A.1 How Information is Provided from Primary Care Practice to Outside Facilities on a Regular Basis
Appendix A.2 Information from Primary Care Practice Sent to Outside Facilities on a Regular Basis
Appendix A.3 How Information is Provided from the Outside Facility to Primary Care Practice
Appendix A.4 Information Provided to Primary Care Practice from Outside Facilities on a Regular Basis
Appendix A.5 Time Lapse from Event to Information Available at Primary Care Practice
Appendix A.6 List Specialist Physicians, Contact Information, and Contact Method
Appendix A.7 Referral/Consult Form
Appendix A.8 Outgoing Referrals – Simple Form
Appendix A.9 Current Method of Communication from PCP to Specialist Physician
Appendix A.10 Current Method of Communication from Specialist Physician to PCP
Appendix A.11 Information Currently Provided to PCP Following a Consult
Appendix A.12 Time Lapse for Information Availability to PCP
Appendix A.13 Current Mechanisms from Primary Care Practice to External Providers/Facilities
Appendix A.14 Current Mechanisms from External Providers/Facilities to Primary Care Practice
Appendix A.15 Hospital Follow-up Workflow
Appendix A.16 Hospital Follow-up Protocols
Appendix A.17 Hospital — Primary Care Practice Sample Agreement
Appendix A.18 Specialist — Primary Care Practice Sample Agreement
Appendix A.19 Sample Care Coordinator Job Description

Appendix B - DEFINITIONS - 79

Appendix C - OTHER RESOURCES

Please log in to submit a review.