Care Coordination is the organization of patient care activities between two or more participants to facilitate the appropriate delivery of health care services. Care Transitions are a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care in the same location. Effective care coordination cannot exist without care transitions. The path to effective care coordination begins with planning through automated workflows, real-time transition data and a communication pathway across providers (Primary Care and Subspecialists) and staff.
The Patient Centered Medical Home (PCMH) model is ideal for Care Coordination and Care Transitions. This model values coordination and continuity of care that are more important to a network of providers than the ones that connect them. Practices that understand the importance of care coordination and care transitions establish strong transitions of care, workflows, and technology to make them work.
The PCMH model is also ideal for transitioning adolescence to adult care, whether that’s from a Pediatric practice to a Primary Care practice, or a Primary Care practice that supports cradle to grave healthcare. The importance of supporting and facilitating this transition provides an excellent foundation of guidance for health care planning, health risks, prevention and communication throughout the patient’s major life transitions.
Primary Care practices caring for youth note that no transfer of primary care will be needed. However, there is a need to implement an adult model of care for when the patient transitions from adolescence to adult care, and subsequently from adult care to geriatric. Plan for the transfer of specialty care to adult medical subspecialists and support broader transition planning that includes issues such as educational attainment, career choices, and independent living needs.
When there are obstacles, there are also opportunities. The need is stronger than ever for the seamless transfer of care and personal health information from pediatric care settings to more adult settings for all to function as independently as possible in promoting their own health as adults. Planned care is the product of a partnership among providers, providers’ staff, youth, families, and caregivers that has become an essential staple of the PCMH model.
The PCMH model is an opportunity where there are obstacles in care coordination and care transition. All patients deserve to experience a model of care. Implementation of planning, decision-making, and documentation processes for patients who are approaching transition need structure for training, continuing education, and research to further the understanding of best practices for care coordination and care transition. To successfully achieve this goal the practice team must receive training, technical assistance and adopt transition-related practices (discussing the office policy, assessing care coordination and transition policy, assessing family readiness, etc.).
Please contact Julie Stephens, Project Director, to find out more about how Care Coordination and Care Transitions can impact your PCMH application.