Care Coordination

What is Care Coordination?

Care Coordination, also known as patient-centered medical homes, are considered by many to be among the most promising approaches to delivering higher-quality, more cost-effective primary care in the United States—especially for people with chronic health conditions. Care is team-based, preventive and comprehensive, rather than one-on-one, fee-for-service or managed. Record keeping and sharing is seamless and electronic, rather than unwieldy and paper-based. Care Coordination is the concept that each patient has close, ongoing contact with a clinician for continuing care, and that this clinician takes the lead on referring the patient to specialists when needed.

But for people living in rural areas, the specialist or tertiary care facility may be hundreds of miles away. Electronic medical records can facilitate communication between primary care and specialty care, but only if the information is transferred in a timely manner. And not all rural practices have EMR capacity yet.

Do reimbursement models need to be tweaked to encourage Care Coordination? Do primary care providers have adequate incentives to utilize Care Coordination? Should there be timeline requirements for specialists or tertiary care facility to send test results, discharge summaries and other information back to the primary care provider? What about broadband access and other technology issues?

What else should be done to improve communication between rural providers and their urban colleagues? Get your seat at the table! Help VRHA develop a strategic plan for rural care coordination advocacy by attending the Care Coordination discussion.

Moderator: Neal Graham

Panelists:

Tony Kuzel, M.D., M.H.P.E.
Chair, Department of Family Medicine
VCU Health System

Vianney Marengo R.N./BSN
PCMH Clinic Care Coordinator
Carilion Clinic Family Medicine Vinton

Day 1 - defining the issues

On the first day, participants had the opportunity to hear a panel discussion on each topic, but the focus was on sharing of information ideas and concerns.  They panelists only had a few minutes to speak, and then the participants were lead in a facilitated discussion to help them identify the top two issues on each topic. 

Day 2- finding solutions

While the first day identified issues, the second day was all about finding solutions.   Each of the top issues from the previous day was given its own discussion table.  Participants were asked to rotate between tables and asked a series of questions so that the issues may be considered from a variety of perspectives which would lead to constructive solutions.