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4 Care Coordination
Pages 47-56

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From page 47...
... Such coordination can be facilitated by procedures for engaging community resources, including social and public health services. At the summit, Martha Whitecotton, representing the voice of the consumer on the opening plenary panel, courageously shared her family's experience navigating the turbulent waters of the health care delivery system with her son, who has major depression.
From page 48...
... . functional ability, in supporting family caregivers, in health education, and in social KEY STRATEGIES services are needed to specify these elements for chronic disease.
From page 49...
... Some examples of interventions currently under way include the following: Lack of care coordination · A depression management toolkit developed jointly by Blue Cross and Blue Shield of Kansas City and New Directions Behavioral Health includes a Continuity of Care Form designed to encourage communications between primary care physicians and mental health professionals. Use of this instrument by providers is monitored by means of chart review.
From page 50...
... A dual strategy Provide Educational Supports was proposed, beginning with practicing clinicians, managers, and educational leaders, The session participants suggested that a major and then progressing through faculty to barrier to providing care consistent with the six currently enrolled students. A core set of aims of the Quality Chasm report is the competencies would need to be developed in difficulty of integrating multiple health these domains of care and then linked to providers to develop and communicate a ongoing licensing and certification programs.
From page 51...
... illustrated by Graph 2 in Box 4-2, quality-of-life One of its interdisciplinary interventions scores (with higher numbers indicating better involves placing certified asthma educators into quality of life) were also found to increase primary care offices for 8 weeks to provide postintervention for both patients with asthma instruction on evidence-based asthma care, and their caregivers (Jones and Portnoy, 2003; practice role modeling, and stimulate behavior Miller et al., 2003)
From page 52...
... 1ST ANNUAL CROSSING THE QUALITY CHASM SUMMIT (Continued from page 51) Graph 2: Caregiver and child quality-of-life scores Qualityof Life for Different Visits 5.40 5.20 efiLfoy 5.00 4.80 Caregiver QoL litauQ 4.60 Child QoL 4.40 4.20 4.00 Unmanaged InitialVisit Visit 2 sequent Visits Sub SOURCE: Reprinted with permission from Jay M
From page 53...
... Kaiser Permanente TriCentral Palliative Care Program The Kaiser Permanente TriCentral Palliative Care Program uses a multidisciplinary approach to coordinate care in the home for patients transitioning from acute to palliative care during the last 12 months of life. After statistics showed that more than 50 percent of Kaiser Permanent TriCentral patients with heart failure, chronic obstructive pulmonary disease, and cancer died in either the medical/surgical unit or the intensive care unit, this program was developed to remedy the mismatch between patient preferences to die peacefully at home and the tendency for the health care system, as currently structured, to steer care at the end of life to the inpatient setting.
From page 54...
... Successful management of chronic conditions and patient registries, was proposed as a viable requires the delivery of a vast array of services, solution to facilitate rapid retrieval and sharing hand-offs to other specialists, and aggressive of patient data and address the problems follow-up. Given this complexity of care, it is associated with traditional paper health records essential that the care team's roles be clearly that inhibit good care coordination, such as delineated and that administrative support be charts being misplaced and missing data (Tang provided for new functions and responsibilities et al., 1994)
From page 55...
... Additional interventions include an environmental assessment for asthma triggers, partnering with the school system to ensure that an asthma action plan is in place, and coordination of medical insurance benefits to help families obtain coverage for uninsured children. This multilevel initiative brings all providers together to center care on the child's needs.
From page 56...
... 2004. Institute of Medicine 1st Annual Crossing the CDC's Behavioral Risk Factor Surveillance Quality Chasm Summit, Washington, DC.


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