Welcome to Care Coordination and Interoperable Health IT Systems, Overview of Care Coordination. This is lecture b, Care Coordination Models. Thank you for taking your valuable time to invest in learning. What it means to coordinate care? As you view and learn from this webinar, you will become better navigators, so you can truly be better guides to coordinate care with your patients travelling through the complex and often frightening healthcare maze. The objectives for this unit, Overview of Care Coordination lecture b are to discuss various models of care coordination and compare care coordination roles and responsibilities In the post-Affordable Care Act models of care across the care continuum. Models of Care Coordination, include Patient-Centered Medical Home, PCMH. Patient-centered Medical Neighborhood. The Collaborative Care Model, Medicaid. Behavioral Health Home, Joint Commission. Care Transitions Program, Eric Coleman. Guided Care, Johns Hopkins Program. Transitional Care Nursing Model, Naylor Advanced-Practice Nursing. Community-Based Care Transitions Program. The Integrating Care for Populations and Communities Aim, IPCA. Previously, the care transitions theme, Jane Brock. Primary Care Teamlet Model. Bridges to Health. Project RED; ReEngineered Discharge, Boston University. And BOOST, Better Outcomes by Optimizing Safe Transitions, Society of Hospital Medicine. The Patient Centered Medical Home is a healthcare model and setting that facilitates partnerships between individual patients, and their personal physicians. And when appropriate, the patient's family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. The PCMH principles are broadly, a set of structures, processes that improve access and reliability of care with a focus on individual patient needs and payment to support all of the joint principals including coordinating whole person care. PCMH joint principals are physician directed care, whole person orientation, coordinated and integrated care. Quality and safety. Enhanced access and a payment system that rewards value, i.e., not resource-based relative value scale. PCMH joint principles include quality and safety, enhanced access and payment system that rewards value, i.e., not resource based relative value scale. Care Coordination models depend on multidisciplinary collaborative partnership relationships where there is mindful and purposeful clinician-patient communication based on trust, respect and shared decision-making to place the patient and family at the center of care. Culturally sensitive care coordination fosters the continuous relationship with a personal physician. Coordinating care for both wellness and illness for whole person care. PCMH's function, as the systems health information repository. Securely holding and sharing whole-person health information necessary for care delivery measurement, and establishing target health goals through shared decision-making. The patient centered medical home team based care with the primary care physician, PCP as the team leader of the care team that includes the patient, is central to the team for decision-making. The PCP takes responsibility for coordinating a patient's health and information for care across care settings, and services over time where shared decision-making regarding care decisions. For example, consultation referrals are agreed upon and coordinated after consultation and collaboration with the patient and family In the PCMH Care Coordination model, specialist physician referrals and consultations are tracked, managed and consultation outcomes documentation is maintained for timely followup evaluations. Test processes, include computer ordered entry and tests are coordinated along with managing test ordering, test tracking, test results notification and followup management. Also in PCMH Care Coordination, population health and chronic disease management systems allow patient population, condition stratification and the identification of high acuity care needs. Systems evidence-based guidelines outline appropriate care. PCMH Care Coordination helps patients choose specialists and obtain medical test results to share, to avoid retesting when necessary. It also informs specialists of any necessary accommodations for the patient needs and helps access other needed providers or health services, including providers or health services not readily available in the patients community, including rural or underserved areas. PCMH Care Coordination tracks test results. Shares information with patients and ensures that patients receive appropriate followup care, and help in understanding results, and treatment recommendations. It also ensures smooth transitions by assisting patients and families as the patient moves from one care setting to another, such as from hospital to home. PCMH Care Coordination has systems in place that help prevent errors when multiple clinicians, hospitals or other providers are caring for the same patient, such as medication reconciliation and shared medical records. It has systems in place to help patients with health insurance eligibility, costs, coverage and appeals or to refer patients to resources that can be of assistance. It has systems in place to identify and address barriers or needs due to individual's social determinants of health. Care Transitions Model of Care Coordination was developed by Eric Coleman. It addresses the problems of patients who are discharged from hospital to home. The advanced practice nurses are trained as coaches and also assists patients, and their families in self-care skills. Johns Hopkins Guided Care Model is led by registered nurses that helps with assessment and care planning. The care team provides care for chronically ill patients, which is coordinated, patient-centered and cost-effective. Mary Naylor from the University of Pennsylvania developed the coordination of care advanced practice nursing visits in hospital, home and by telephone as intervention for older adults hospitalized for chronic health conditions. The Community-Based Care Transitions Program promotes seamless transition from acute hospital care to post-acute care back to the home community. Skilled nursing care or home-healthcare. Providing a model of best practice tools through a CMS supported Care transitions quality improvement organization support center, QIOSC to engage, provide support and help the entire community to build better healthcare coordination strategies, coalition charters, data analytic tools and information on mapping and network analysis. The Bridges to Health Model offers a way to think about developing programs for segments of the population that meet patients needs for coordinated, integrated care delivery programs and services that meet the needs of each of the populations outline in the model. When these programs are aggregated, they should improve the quality and efficiency of care coordination for the entire population. This concludes lecture b, Care Coordination models of unit one, Overview of Care Coordination. In summary, care coordination requires collaboration and communication between the primary care physician team leader, care team and the patient. There are various post-Affordable Care Act models of care coordination across the care continuum.