Seven Key Points For Improving Patient Care Coordination Between Health Care Providers
Health care providers in every health care setting should address the following to improve patient care coordination during care transitions to assure timely, effective, safe, and thorough transfer of information from one setting to another:
- Patient Safety
- Communicate patient safety concerns during transitions to other health care settings
- Identify potential safety issues: falls, inadequate support system, medications, environmental issues - Medication Reconciliation
- Determine the comprehensive list of patient’s medications at admission and discharge from all health care settings
- Communicate the patient’s accurate medication profile when moving to another health care facility (Emergency Department, Hospital, Home Health, Nursing Home) - Patient Self Management
- Educate patient/caregivers regarding self management strategies
- Empower patients/caregivers to take an active role in their health care treatment - Rehospitalization Risk
- Communicate ‘at risk’ status for rehospitalization during transitions to other health care settings
- Target interventions with patients with a history of chronic conditions, multiple hospitalizations/emergency room visits and other high risk indicators - Immunization Status
- Determine current immunization status
- If immunization is not current, encourage patients to obtain the influenza and pneumoccal vaccine
- Communicate immunization status during transitions to other health care settings - Disease Management
- Educate patient/caregiver on disease management: focus on understanding disease and treatment and the importance of adherence with treatment regimen - Right care at the right time, every time
- Ensure patients are treated in the most appropriate setting to meet their needs
- Collaborate with other health care providers in other health care settings and with patient/caregiver to establish optimal plan of care for patient