Welcome to Care Coordination and Interoperable Health IT Systems, Overview of Care Coordination. This is Lecture c Long Term Coordination. Thank you for taking your variable 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, traveling through the complex and often frightening healthcare maze. The objectives for this unit, Overview of Care Coordination, Lecture c are to discuss specialty care coordination. Discuss long term care post acute care, and identify stakeholders in care coordination. Patient-Center Medical Neighborhood, PCMN, is an extension of the patient centered medical home model of home care coordination to the medical specialist. Patient care is coordinated and managed among primary care specialists and hospital systems. With the ordering and referring primary care physician team leaders as the hub of the medical neighborhood. Health care organizations in a community bring engaged patients, primary care practices, specialists, subspecialists, hospitals, pharmacies. And all the patient's healthcare points of contact together around PCMH elements within clinically integrated networks. Care coordination technological infrastructure includes policies, processes and systems to safely share information, track and monitor consultation and specialist referrals. And follow-up care for patients transitioning specialists and primary care in the medical neighborhood. Evidence-based medical / clinical guidelines systematically integrated for diagnosis and treatment of a wide variety of diseases and conditions support specialty care coordination. Patient Centered Medical Neighborhood Goals are to prepare for and implement new reimbursement methods, measuring outcomes across the care continuum. Align diverse stakeholders in the medical neighborhood, and implement planned and coordinated care processes specialized for chronic conditions and preventative care. Patient Centered Medical Neighborhood goals include developing a clinical integration system to align practices and providers around systems thinking approaches to meet patient centered organizational goals. Understanding, planning for, and adapting risk-stratified care management aligned with care coordination. And meaningfully using health information technology to manage population utilization needs for specialist care in order to better provide accountable care. Medical specialist consultation tracking policies establish a critical referral tracking system that ensures critical consults are documented and captured at the time of the referral request. Critical referrals are scheduled, captured, and documented for tracking with appropriate specialists. And policies ensure follow-up tracking with specialist providers and patients will occur within a designated time. For better patient and family care coordination and health information flow, partnerships for patients are established between primary care and specialists. Specialists collaborate and enter into referral agreements for better care coordination with care teams. Referral agreements outline which clinical conditions are best referred and managed by this specialist. And how and when reports are delivered back to the primary care physician in a timely manner. Specialists build relationships founded upon mutual commitment to addressing the needs of the patient and family. Clear roles and responsibilities are agreed upon for each of the specialists and primary care teams. Processes and guidelines for communication and follow up are established. The patient and family are a part of the team where shared decisions are made to coordinate the flow of health information across and between primary care and specialist clinicians and their patients. To include providing agreed upon information from and back to the referring primary care physician team leaders and out to the expanded team, which includes the specialists. The Home-Based Chronic Care Model and the Integrated Care Model by the Sutter Care for Integrated Care. The Home-Based Chronic Care Model and the Integrated Care Model, ICM, by the Sutter Center for Integrated Care include community-based care. Home health, custodial care, medical house calls, hospital at home, and palliative, hospice and advanced illness care. Skilled nursing home facilities, rehabilitation facilities, home health and hospice are examples of the long-term, post-acute, and chronic health condition care settings. Where care is ordered and referred by the primary care physician team leaders and care coordination expands to multi-disciplinary teams. Care teams are responsible for ongoing care coordination and securely maintaining and sharing pertinent health information. Shared plans of care are developed and designed to meet all of the individual patient's unique care needs. To include the right combination of prescribed post-acute services that may include skilled nursing, rehabilitation, therapies, nutrition, counseling and household support throughout the lifespan. Care coordination includes periodic assessment and review of needs and abilities on an on-going basis. Keeping care teams informed about changes in patients' conditions, addressing needs related to social determinants of health. Sharing patient information with care teams and collaborating for self care management with the engaged and activated patient and family. Care coordination from facilities to home lead to decreased length of hospital and facilities stay. And increased penalties for readmissions have increased interest in how care coordination for transition from hospital to home can benefit patients and families. Hospitalized patients can be discharged to home to rely on physician ordered and coordinated care through home care services. Which may include end of life hospice, or palliative care, and also any type of appropriate home skilled nursing care or simple attendant household assistance in the home. Patient and caregiver interviews reveal that satisfaction with home health care and hospice or palliative care services have proven by research to be positively related to receipt of needed care. Information from the home care staff about medications, equipment, supplies, and self-care. Caregiver burden was inversely related to care coordination for receiving information. Which may be education and information delivered through technology systems from integrated healthcare organizations. Recommendations for improving care coordination in the transition from hospital to home at the near end of life. Includes providing more information, more reassurance and emotional support and more household assistance. Caregiver burden was inversely related to care coordination for receiving information. Which may be education and information delivered through technology systems from integrated health care organizations. Recommendations for improving care coordination and the transition from hospital to home at the near end of life. Includes providing more information, more reassurance and emotional support, and more household assistance. Stakeholder perceptions and valued attributes of care coordination and care delivery experiences that relate to care coordination include sharing health information through improved technology. Participating as expanded team members of the patient centered medical home. And sharing decision making in agreed upon physician orders for patient care prescribed by the ordering and referring primary care team physician. These valued care coordination attributes include data-driven management for coordinating care through measured care assessment. Care planning, monitoring, reviewing, providing uninterrupted care services, continuity, trusting partner relationships, and collaborative shared decision-making. Stakeholders in care coordination include patients and families, communities, federal, state, and municipal governments. Consumers and consumer groups, advocacy and public policy groups, health care reimbursement entities. Health plans,government plans, employers and purchasers among others. Stakeholders in care coordination include, PCMH care teams and care coordinators, home caregivers, nursing and home attendant service providers. Care managers, physicians, medical neighborhood, health information technology systems group, telehealth, telemedicine and virtual care groups. Patients and families, perhaps the most invested stakeholders in care coordination include the patients and families. Who traditionally have passionately performed most of the care coordination for a loved one. Although they often have accomplished the care coordination with no formal training in health care. Entities and health care organization stakeholders responsible for reimbursement of health care support shared savings models, value based models. And models where risk adjusted, comprehensive primary care payments from public and private payers, as well as employer groups. Strategically promote care coordination and equality outcomes and utilization improvement measure. Care coordination is a stakeholder priority that will focus on controlling and reducing the total cost of health care for an individual or population. Because increasing appropriate navigation across care transitions has proven to decrease costs and improve outcomes. Advocates and policy makers, regulatory policy makers and advocates in the public government, and private sectors, are among the many stakeholders in care coordination. Addressing aspects of the health system that can eliminate barriers to better care coordination. Policy makers, agencies, and government leaders at the state and federal levels drive health system regulatory reform. Based on information and data metrics from programs that incorporate key features of care coordination integrated into health care reform models. Such as patient-centered medical home and neighborhood, accountable care organizations, health information technology systems and payment reform systems and programs. Employers and purchaser stakeholders, redesigning benefits programs to incorporate health care coordination and systems technology features, into innovative payment models. Works to share best practices, and resources based on successful models including workplace wellness initiatives, increasing presenters. Prevention programs, benefit structures, each are tied to stakeholder positions for improved health. Each are tied to stakeholder positions for improved healthcare coordination and systems technology. This conclude Lecture c, Long-term Care Coordination of Unit 1, Overview to Care Coordination. To summarize, care coordination requires collaboration and communication between the primary care physician team leader, care team and the patient. In long-term, teams are responsible for ongoing care coordination and securely maintaining and sharing pertinent patient health information. There are a variety of stakeholders in care coordination, the most important being patients. To summarize the unit overview to care coordination, 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. Patients are the most important stakeholders in care coordination.