Coordination of care
Care coordination is a broad term and can have different meanings across healthcare settings. Best practices in care coordination should include a model that establishes a common language, sets expectations, and educates the care team to ensure all members of the integrated care system are aligned. The goal of an integrated care system is to ensure members receive a whole health care experience. The model should consist of clear definitions and criteria for risk stratification of the patient population. Strong risk stratification provides a method to tailor care to individuals at greater risk. The care coordination model should also include the following:
- Identification of the interdisciplinary care team, including medical, behavioral, pharmacy, and peer and community team members, to address all health-related individual needs, enabling all members of the care team to work across the continuum.
- Comprehensive assessment to identify the members' needs and barriers to care.
- Communication strategies such as rounds, warm handoffs, connected Electronic Health Records or Electronic Medical Records (EHR/EMR), and sharing of health records to allow for early intervention and preventative measures to keep members healthy.
- Robust monitoring system for follow-up care.
- Methods to address polypharmacy and indiscriminate use of benzodiazepines and other controlled substances.
- Ongoing improvement activities to evaluate interventions, monitor quality, and refine risk stratification methodologies.
Coordination of care resources
- Agency for Healthcare Research and Quality: Strategies for Integrating Behavioral Health and Primary Care
- Agency for Healthcare Research and Quality: Care Coordination Quality Measure for Primary Care (CCQM-PC)
- American Psychiatric Association: Collaborative/Integrated Care
- Centers for Disease Control and Prevention: Training: Care Coordination in Treatment of Substance Use Disorders
- Centers for Medicare & Medicaid Services: Care Coordination
- Substance Abuse and Mental Health Services Administration: Care Coordination for Certified Community Behavioral Health Clinics (CCBHCs)
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