Reducing Care Fragmentation

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. Case Studies 18. FAMILY care NETWORK: Developing Agreements between Primary care and Specialty GENESYS HEALTH SYSTEM: Developing Linkages with Community HUMBOLDT COUNTY: Tracking Referrals through an Electronic Referral SAN FRANCISCO GENERAL HOSPITAL: Connectivity through Electronic OKLAHOMA SCHOOL OF COMMUNITY MEDICINE: Developing and Implementing an Electronic Consultation V.

mental health center to review and update her depression treatment. Ms. G had difficulty getting an appointment at the center, and finally saw a psychiatrist she had never seen before. At the mental health center, her blood pressure was 220/124 and Ms. G complained of headache, as well as fatigue. The psychiatrist, who had received no information

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  Center, Care, Reducing, Fragmentation, Reducing care fragmentation

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