CARE COORDINATION DEFINITION FROM URAC

“Care Coordination is the deliberate organization of patient care activities among two or more participants (including the patient and/or family) to facilitate the appropriate delivery of health care services.  Organizing care involves marshaling personnel and other resources to carry out all required patient care activities, which is often managed by the exchange of information among participants responsible for different aspects of the care.”

SVHP operationalizes population health management using two distinct tools:

  1. Case Management – the face – to – face activity done at the local level by the healthcare team in each patient – care setting.
  2. Care Coordination – the SVHP activity which transcends individual providers and settings and continuously oversees, analyzes, and resolves procedural problems system – wide at the enterprise level and in collaboration with the membership. This enhances the capacity of SVHP to integrate clinical care between all members and offer quality cost – effective care meeting patient expectation and service standards which are sustainab le.
How is this achieved? Care coordination and integration activity proactively target and prioritize the gaps in care evidenced in data from multiple sources such as payer originating reports, publicly reported dashboards from CMS, analytics of raw data, and the monitoring of various network activities. SVHP through the committee structure and with the support of staff works with members to address those gaps through strategies which are relevant for the setting and which have evidence to support their use. Undergirding the operationalization of the SVHP model are:
  1. Requirement that all primary practices are in the process of achieving or have achieved Patient Centered Medical Home
  2. Progressive integration of SVHP’s Playbook (the organization’s detailed evi dence – based clinical guideline & resource available at point of care) to all organizational member settings. It contains:
    • Transition care: Adherence to institutional best practice processes and communication patterns
      • Attention directed to more than 140 transitions
      • Standard institutional process to reduce variation
      • Promotion of a Health Summary Record to provide key medical information at every patient care contact point
      • Referral coordination reinforcing the clinically integrated network
    • Physician compendium: details the organization’s disease – specific care and preventive requirements to improve overall patient care and reduce complications of disease
    • Requirements to meet payer metrics
    • Policies and plans
    • Pathways developed within the network

SVHP Vision

“Quadruple Aim” …quality cost – effective care with patient satisfaction and reflecting the IOM description of high quality care:

  • Timely (without unnecessary delays)
  • Safe (transitions are planned, managed at point of care)
  • Effective (based on best practices)
  • Patient – centered (respectful of patient preferences)
  • Efficient (the right care at the right time in the right place and avoiding unnecessary duplication)
  • Equitable (the standards apply to all patients)

 

For more information regarding Care Coordination, please contact Colleen Swedberg, Vice President of  Strategy (colleen.swedberg@stvincentshealthpartners.org).

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