Transcription of Reducing Care Fragmentation
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Reducing care Fragmentation A TOOLKIT. FOR COORDINATING care . Reducing care Fragmentation 1. Contents I. Introduction 1. MS. G: A Case Study in Fragmented II. The care Coordination Model 4. care Coordination MS. H: A Case Study in Coordinated III. Change Package and Tools 8. Key Change / Activities #1 KEY CHANGE: Decide as a primary care clinic to improve care #2 KEY CHANGE: Develop a referral/transition tracking Patient #3 KEY CHANGE: Organize the practice team to support patients and families during referrals and Relationships and #4 KEY CHANGE: Identify, develop and maintain relationships with key specialist groups, hospitals and community #5 KEY CHANGE: Develop agreements with these key groups and #6 KEY CHANGE: Develop and implement an information transfer IV.
managed to prevent harm to patients from medical or administrative errors. Care coordination, a core function of the patient-centered medical home (PCMH), has been defined 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
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