What does it mean when we talk about “care coordination,” or “integrated care?”
Coordinated or integrated health care aims to optimize communication and collaboration between all members of your health care team—doctors, nurses, and pharmacists, for example—so everyone’s on the same page to deliver you the right care at the right time, without “dropping the ball,” undue waiting, or duplication of efforts.
Listen to the latest episode of our podcast, Healing on the Home Front, where discuss connecting services across the health care continuum.
Home is the Center of Coordinated Health Care
For many individuals, engaging a home health care provider is the entryway to what truly coordinated, integrated care looks and feels like. Having the benefit of getting to know a client well in their own environment, a home care team is able to observe and assess everything that may be impacting one’s health and well-being, and can advocate on the client’s behalf to get them the resources and services they need.
What has Changed?
According to old models, health care used to be delivered episodically. An episode, or event, would send you to the hospital—a sudden illness or injury, for example. You’d be assessed and treated for that episode, then a doctor would discharge you back home. And once you got home, you were largely on your own.
Today, in new models of coordinated or integrated health care, there are incentives to think more holistically about what care services can help you stay well, improve your health and quality of life at home, prevent adverse events, and keep you out of the hospital.
So, for example, instead of just sending you on your way, your doctor’s office will make sure your local pharmacy has your prescription order, and your doctor will order home health care services to provide the follow-up nursing, therapeutic, or personal care you may need.
What is a Personalized Care Plan?
When you become a home health care client, you’ll be introduced to a registered nurse clinical manager. This individual takes the lead on making sure all your health care needs are met according to your wishes.
Your clinical manager will visit you at home, get to know you and your family, discuss your doctor’s order with you and any interested loved ones, and work together with you to develop your personalized care plan. The plan will address your doctor’s orders and your own health goals, and it will outline exactly how and when home care services will be provided to help you achieve your goals.
The clinical manager then assembles and trains an interdisciplinary team of nurses, therapists, or other caregivers to provide your specialized care services. As the client, you always have the power to help select your caregivers and even replace one if your personalities feel incompatible. But the beauty of a home care team is that they already know you, and they’ve probably already made the perfect match.
Depending on your unique situation, a personalized care plan may be short-term—for example, to help you recover from a surgery or to help you manage a chronic condition such as diabetes or COPD. Or it can be long-term to help you live safely and independently with a condition such as dementia, traumatic brain injury, or multiple sclerosis. And of course, as time goes on, the clinical manager stays in continuous communication with your doctor and makes sure your personalized care plan adapts to new needs and information.
Benefits of Care Coordination in the Home
Stacey Rice, BSN, RN, CRRN, CCM works as a BAYADA Transitional Care Manager in a hospital, helping patients prepare for their discharge and coordinating the home health care services and medical supplies they’ll need. She describes the benefits of home-based care coordination this way:
“There are so many intangibles that a home health care team brings to the table, that can’t come from any other professional source or setting. The peace of mind that caring human beings understand your everyday challenges and are here to help. Real-life health education that helps clients and their loved ones feel confident and empowered in their self-care and health care decisions. Everyday oversight and interventions to prevent illness and injury. Coordination of medical supplies, bills, and services…” says Rice. “All of these very personalized support systems relieve stress on the entire household and create a more calm, peaceful home environment that allows you to live your best life and achieve the best possible health and well-being.”
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