Delivering Successful Care Coordination: Creating the IT Foundation for Accountable Care

The success of accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) will depend upon physicians who embrace the concept of managing care across the care continuum and leading teams of professionals committed to evidence-based medicine while delivering on continuous quality improvement.

The success of accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) will depend upon physicians who embrace the concept of managing care across the care continuum and leading teams of professionals committed to evidence-based medicine while delivering on continuous quality improvement.

Today, much of the “coordination” conversation is around who is or who should be the “quarterback” on behalf of the patient / member. Is it “Friendly Insurance Company’s” Case Manager, Condition Management Nurse, Inpatient Review Nurse, and/or Discharge Planning Nurse? It is the PCP, their Care Coordinator, one of several specialists the patient is using or one of their nurses? Keeping with the football motif, one thing is for sure, the patient feels like the football. They are handed off, thrown downfield, punted and sometimes fumbled.

The Stanford University-UCSF Evidence-Based Practice Center defines care coordination as "the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care."

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Source: Healthcare Informatics