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Care coordination best practices for new independent primary care practices


Providing high quality care is the ultimate goal for your new independent primary care practice. A significant aspect of healthcare that leads to improved outcomes for your patients and success for your new practice is care coordination. There are a number of care coordination best practices designed to help guide you through the launch and continued operations of your new independent primary care practice.

Although many definitions of the care coordination concept exist in the healthcare field, the model of healthcare delivery has been essentially created out of the growing prevalence and increased cost of chronic conditions among patient populations.

Evidence has shown that care coordination can lead to improved results for patient health and improved cost outcomes. Health reform models include care coordination as well as the need to attend to behavioral health needs of the patient populations with chronic health conditions.

The Agency for Healthcare Research and Quality (AHRQ) has developed a working definition of care coordination:

Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.

Care coordination is seen as a means of achieving coordinated care focused on integrating and synchronizing care across providers, organizations, and settings.

Best practices for care coordination include a range of functions on the independent physician’s part:

  • Establish accountability within the practice, making clear the responsibility of participants in the patient’s care for a particular aspect of that care.
  • Communicate clearly and regularly, with the patient, the patient’s support network, and the patient’s other healthcare providers.
  • Communicate via information transfer (e.g., flow of information, medical history, test results) optimizing the features of interoperable electronic health records (EHRs).
  • Create a proactive plan of care that includes coordinating with other providers and involving the patient in their own healthcare, jointly created and managed by the patient and/or family and healthcare team, outlining the patient’s current and longstanding needs and goals for care and/or identifying coordination gaps.
  • Align resources with the patient and population need, assessing the needs of patients and populations and allocating health care resources according to those needs.

Closing the care gaps is an important aspect of care coordination best practices as well. It’s critical for improved outcomes and reduced costs to decrease duplications and avoid errors. Sharing patient information with relevant providers can help ensure the care provided is as effective and efficient as possible.

An interoperable EHR enables providers to electronically share patient information that can be significant in care coordination, improving the process of providing care to patients as those patients see specialty providers, are admitted to a facility for care, and undergo lab and diagnostic tests that determine their plan of care.

Care coordination involves effective cross-communication between providers. The right EHR solution encourages collaborative care with a centralized dashboard featuring the patient’s medical data, visit notes, and test results, all of which can be managed by the providers attending to the patient’s healthcare needs. Electronically accessing patient information instantly allows you to make more informed decisions about your patient’s care, leading to improved outcomes.