This implementation guide from the Safety Net Medical Home Initiative includes useful evidence and practical suggestions for improving care coordination, one of the essential elements of medical homes. The guide defines care coordination as “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” The elements of effective care coordination include:
- Linking patients with community resources to facilitate referrals and respond to social service needs.
- Providing care management services for high risk patients
- Integrating behavioral health and specialty care into care delivery through co-location or referral protocols
- Tracking and supporting patients when they obtain services outside the practice
- Following-up with patients within a few days of an emergency room visit or hospital discharge.
- Communicating test results and care plans to patients/families
Effective care coordination programs have accountability, patient support, relationships and agreements, and connectivity.
The Safety Net Medical Home Initiative is funded by The Commonwealth Fund and eight other funders, with technical assistance from Qualis Health and the MacColl Institute for Healthcare Innovation at the Group Health Research Institute. The initiative is working with five regional coordinating centers, which are each supporting the implementation of patient-centered medical homes in over a dozen safety net clinics.
Additional resources on this change concept are available from the Safety Net Medical Home Initiative website.