Care Coordination Solutions & Tailored CCM Programs

What is Care Coordination?

Care coordination is the process of ensuring that all healthcare providers involved in a patient's care – including medical services, pharmacies, diagnostic tests, therapies, and other treatments – work together to provide timely, effective, and efficient care. This level of communication and collaboration is especially important for patients who require multiple healthcare services, such as those with chronic conditions or those who are transitioning between different levels of care, such as going from a skilled nursing facility to home care.

Care coordination is typically carried out by a care manager, who serves as the point person for the patient and their family, as well as for the healthcare team. However, responsibilities can vary between healthcare facilities.

Primary care coordination:
A guided primary care approach utilizes the skills of a registered nurse (RN) to care for patients across multiple chronic health conditions. The RN will work alongside the primary care physician to ensure all aspects of a patient's care are covered.

Acute care coordination:
This coordination style involves patient transition planning following emergency treatment and discharge. From here, coordinators will schedule follow-up visits, order prescriptions, and provide patient instructions.

Post-acute and long-term care coordination:
Patients in a skilled nursing facility require ongoing medical care and daily assistance upon discharge. Care coordination ensures the smooth transition between the subacute environment and home, and verifies that the care plan aligns with patient goals for the best possible quality of life.

Doctor talking to senior woman in hospital bed-1

The Benefits of Care Coordination

1. Better Understand Your Patient's Health Needs

Care coordination requires a comprehensive view of a patient’s medical history, treatment plan, and goals and centers on strengthening the communication between all providers and support persons involved in a patient’s care. This level of insight and collaboration allows for highly personalized care planning that adapts as needed to ensure that the right care is administered at the right time to achieve patient goals, improve safety, reduce the risk of medical errors, and meet patient needs as they change over time.

2. Improved Efficiency for Care Services and Providers

Care coordination uses advanced technology and communication systems to increase efficiency and cost-effectiveness throughout facility operations and the delivery of medical services. By centralizing patient information and creating direct provider access to an individual’s care plan, care coordination can improve visibility across the entire care continuum, reduce unnecessary medical expenses, and streamline collaboration between providers across multiple facilities to deliver care faster and safer.

3. Actionable Information for Encouraging Patient Engagement

Actionable information in patient care coordination refers to information that is relevant, timely, and specific enough to be acted upon by the patient or the healthcare team, such as details about a patient's diagnosis, treatment options, medication regimen, or care plan. When patients are provided with actionable information, they are better equipped to understand their health condition, take an active role in care, and make informed decisions. This increase in patient engagement improves patient outcomes and reduces healthcare costs over time.

4. Strong Communication for Coordinating Transitions

With greater communication and centralized access to detailed, relevant information, such as patient medical records, current health, treatment plan, and future goals, providers can better predict delays and overcome barriers to care. Greater foresight also allows providers and facilities to coordinate appointments, arrange for transportation, and ensure that patients and families understand what to expect at all stages of treatment.

The Medrina Approach to Care Coordination

Care coordination is extremely valuable to a healthcare facility, but it can be challenging to organize on your own. Our approach to integrating a successful care coordination program at your facility is unique in several ways:

Tailored to Your Facility
As a physician-owned company, Medrina understands what your healthcare facility needs to succeed. Our team of physiatrists and care coordinators collaborate with your team to structure the most effective care coordination strategy.

Shared Goals & Values
Together, we can expand the limits of rehabilitative care in subacute and long-term settings. By focusing on both the clinical and social determinants of health (SDOH), our Care Coordination program has been shown to reduce preventable readmissions by 35%.

Physician Support
Medrina’s dedicated physician support adds qualified physiatrists to your healthcare team. This program provides consistent weekly supervision, hands-on care, and increased coordination through the discharge process. We can be wherever you need us most.

Develop
Your Care Coordination Plan Today

Work one-on-one with the largest physiatry group in the nation to develop high impactful care coordination plans. We believe in leveraging teamwork and collaboration to create seamless patient experiences. Contact the experts at Medrina today for more information on our programs or staffing services.

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Care Coordination Solutions