“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 Care Coordination Process

SVHP will participate in Care Coordination services across the clinically integrated network while utilizing existing case management services in the hospital, ambulatory, ED, urgent care centers and SNF’s by identifying the additional Care Coordination needs and develop processes across the continuum for a seamless transition of care.

SVHP will coordinate care and deliver appropriate preventative or disease/condition specific services by integrating evidence-based guidelines and appropriate care coordination and self-management processes.

Our goal is to Meet Patient Needs and Preferences in the Delivery of High Quality, High Value Care, bridging the gaps between Primary Care, Specialty Care, Inpatient, Mental Health Services, Long-Term Care, Medical History, Test Results, Home Care, Informal Caregivers, Patient/Family Education and Support, Medications/Pharmacy, and Community Resources.

The PHO Development of Transitions of Care from In Patient to Home includes:

Assessment, Review of Tests ordered and Performed Treatment (Medication Reconciliation), DME need, Patient Education, D/C planning from Home Care, Communication with PCP/Specialist offices regarding the Plan of Care.

SVHP is also developing a program with Ambulatory Practices and In Patient.

For more information regarding Care Coordination, please contact Colleen Swedberg, Director of Care Coordination and Integration, or by phone at (203)275-0209.