Main content

    Coordinated Care

    Coordinated care model

    Integrated Care Management (ICM) model goals around coordinated care

    • Facilitate continuity of care: coordinating care across providers, settings and time.
    • Collaborate with and engage the entire healthcare team. A focus on shared goals by all team members from all sectors to align work which promotes progress and enhances clinician engagement and experience of work.
    • Provide personalized guidance and support as care needs change and as patients move though the healthcare system. Assistance with navigation and patient advocacy enhances patient satisfaction and experience of care.
    This ICM model principle places a strong emphasis on best practices in communication and coordination with the care team. ICM facilitates coordinated care management across providers, settings and time through the implementation of evidence-based tools to support:

    ✓Multidisciplinary collaboration:
    • Adhering to high functioning team principles of defined roles, shared goals and clear communication.
    • Coordinating care and facilitating collaboration: SBAR for the provision of actionable information, dashboard use for meaningful data exchange and total team accountability for outcomes.
    • Recognizing that the patient is the central member of the team.
    ✓Planning for all care transitions:
    • Identifying patient risk and allocating resources based on risk.
    • Using best practices and interventions to mitigate risk.
    • Standardizing high quality care through the use of protocols and decision support.
    • Focusing care on key transition pillars: red flags, medication reconciliation, follow-up, personal health record (PHR), with an added emphasis on medication management.
    • Providing transitional support from hospital to home, MD office to home, home to SNF, home health to hospice.
    • Initiating intensive care management programs as indicated.
    • Referring to services and community resources as needed.
    • Scheduling a face-to-face follow-up visit within 48 hours of discharge
    ✓Enable meaningful transfer of information:
    • Using consistent channels to share key actionable information, accessed by all team members, across all settings.
    • Communicating best practices: universal precaution approach to communication encompassing accessible and actionable tools such as the award-winning stoplight forms and a personal health record (PHR).
    • Using supportive technologies to improve care, decrease avoidable hospitalizations and reduce cost.