High-performing ACOs were able to successfully create physical space for, and incorporate, care coordinators
into large primary care practice sites, while low performers described ongoing negotiations regarding the inclusion of care coordinators
into the existing primary care workforce.
seems unable to articulate his situation adequately enough for the care coordinator
to understand what is needed.
Conference Focus: The critical role of embedded care coordinators
in population risk management as well as results achieved, including the following:
The integrated team will include a primary care provider, psychiatrist, behavioral health specialist, patient care coordinator
, peer support specialists, community health RNs, certified alcohol and drug counselor, among others.
For those patients whom the RN care coordinator
deems not meeting the established scheduling guidelines for bypass of the triage process, a referral specialist (individual with managed care orthopedic or neurosurgery background and extensive training in medical terminology and advanced training in telephone communications) contacts the patient via the telephone and obtains a detailed spine health history following a preset questionnaire of patient data elements specifically designed to capture the patient's current history of illness, work history, medications, previous treatment options explored, and diagnostic tests completed.
Even with the increase in prescription costs, the researchers estimated that the care coordinator
program saves an average of $334 per member per year.
Prior to the meeting, the care coordinator
notified one of the parent partners in the practice about a new premature baby to be discussed at the case conference.
The patient is then contacted by the care coordinator
and offered the option of joining the program at no cost.
Jim Flynn, CUPE National Representative and long-term care coordinator
says the decision will bring these workers' wages "in line with other privately-owned homes in Ontario.
Family planning meetings are organized by a care coordinator
trained in the wraparound approach and are held monthly, or as needed, to design, revise, and evaluate a plan of care for the family in the presence of formal and informal supports.
Upon undergoing a cartilage biopsy, the patient will be enrolled in the program and a dedicated Carticel Care Coordinator
, employed by US Bioservices, will be assigned to the case.