Care Coordination Agreements In The Veterans Healthcare Administration

Social network analysis could be used with CC model data to understand the network of recommendations and collaborators involved in the care of patients in a CC team. This type of analysis would help teams strengthen and formalize relationships with staff, if necessary. If the data show, for example, that the team often works with the cardiology clinic for a large portion of its patients, it may consider creating a CC agreement with formalized communication methods that would streamline collaboration. Abbreviations: CPRS, Computerized Patient Record System; DM, diabetes mellitus; IDT, interdisciplinary team; NP, nurse practitioner; PACT, patient care team; PCP, primary service providers; PIM, PACT Intensive Management; RN, registered nurse. In the CC model, the Atlanta PIM team consisted of 2 nurses (NP), 2 social workers (SW) and 1 nurse (RN). After registration, the PIM team conducted comprehensive assessments of the home and provided intensive management of care for medical, social and behavioural needs. The main pillars of care management for at-risk patients were based on previous work, home visits, telephone disease management, joint participation in patient appointments, transition care management, and interdisciplinary team meetings focused on coordinating care between PACT and all patient-required services. 11.19 The OIG recently conducted a review to determine how local management agencies and inter-community health care and assistance providers use social assistance services in their respective communities.11,19 to exchange and coordinate information. patients enrolled in an IED facility and to identify barriers that may prevent their use. In order to improve the quality of the CC model and to assess the factors that could lead to sustainable use in clinical practice, a qualitative evaluation through consultation, survey or usability testing with employees would be beneficial in identifying strategies to increase acceptance by clinical providers.

This type of evaluation will add knowledge about the CC model implementation process, including contextual barriers or moderators, feasibility of use during day-to-day operation, the versatility of model use in team-based maintenance construction, and overall presentation satisfaction.