Module 14: Patient Care Coordination and Education Flashcards
Care coordination definition; importance
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
Lack of care coordination contributes to increase in health care cost. The affordable care act worked to increase care coordination while decreasing costs
Team-based patient care
Each team member (Providers, patient, and support) is accountable for providing quality care. Requires communication among all members of the team. The patient is the focus.
PCMH
Patient-centered medical home model - a common team-based patient care program where patient treatment is most often coordinated through the primary care provider. Goal of a centralized setting that facilitates parternships between the patient, the provider, and the patient’s family
ACO
Accountable care organization - groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients. Relationship to the community - might have outreach programs.
The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.
Three main goals of the ACA
Expand health insurance coverage
Shift the focus of health care delivery system from treatment to prevention
Reduce costs and improve the efficiency of health care
Core function of a PCMH: Comprehensive care
All of a patient’s needs, not just medical and physical concerns
Core function of a PCMH: Patient-centered care
Patients and families are core members of the team
Core function of a PCMH: Coordinated care
All specialty care, hospitals, home health care, and community services are overseen by provider-directed medical practice
Core function of a PCMH: Accessible services
Providing tools (open-scheduling, communication with providers, etc) through patient information web portals
Core function of a PCMH: Quality and safety
Delivering evidence-based medicine that is assessed by collecting safety data and measuring and responding to patient experiences
TCM; TCM nurse
Transitional care management.
A TCM nurse communicates frequently with the provider’s office and accompanies the patient to follow-up visits, also educates the patient regarding managing their own care and encourages patient and family to take an active role in maintaining health
Model does not provide ongoing care but is designed to help the patient and family caregivers
Medical assistant role in discharge
Communicates and documents patient information to the provider
Making sure reports are available prior to the visit
Confirm all reports are available to the provider before a scheduled appointment. A request for all reports including the discharge summary needs to be sent to the provider on the day of the appointment
illness vs wellness care
Wellness care includes teaching patients the importance of a healthy lifestyle and the need for preventive wellness checks, including recommended immunizations
determinants of health
The interaction of personal, social, economic, and environmental factors influences a persons health. Behavior determinants can be altered by modifying factors like diet, exercise, smoking/drugs, but biology and genetics cannot be modified
MACRA
Medicare Access and Chip Reauthorization Act - replaces the former Medicare reimbursement schedule with a pay-for-performance program
that focuses on quality, value, and accountability.
MIPS and APM are two payment tracks available through MACRA that determine what Medicare will reimburse providers
Four performance categories for medicare
Quality, cost/resource use, clinical practice improvement activities, advancing care information
Preventive care section of chart
Medical assistant may be responsible for going through a patient’s chart to check:
Due dates of preventive testing (pap smears, colonoscopies, mammograms)
Due dates of immunizations (on CDC website)
Due dates of patient care management items (HgbA1c, cholesterol testing)
Expired or soon-to-be expired prescriptions
Medical assistant responsibilities during visit
height and weight measurement, blood pressure, radial pulse, respirations, and temperature
Ask about reason for visit, any questions or concerns they want addressed during the visit, any health status changes
Perform medication reconciliation, need for any refills
Screen for any health conditions per facility protocols (fall risks, mental health, etc)
Educate the patient regarding preventive services based on standing orders, discuss any needed or recommended immunizations
Transcribing for provider, documenting all information
Meet with patients and relatives to discuss diagnosis, symptom management, treatment options, prescribed medications, dietary restrictions -> liaison between the provider and the patient and helps to reinforce instructions and ensure comprehension
Health coaching responsibilities medical assistant
Help educate the patient in regard to compliance, treatment options, and adopting a healthy lifestyle. Develop a rapport with the patient and establish trust
Speak at an adequate pace, make eye contact, provide written material in lay language at patients reading level. Anticipate barriers in learning and react appropriately.
Have patient restate or demonstrate the provided information before ending the education session.
Coordinating care with community agencies
Be aware of community services and offer contact information/brochures. Lists can be organized according to patients’ condition, age, or socioeconomic status
Methods to facilitate patient compliance
Communication is best method - use telephone calls, email on secured server (accounting for HIPPA and pt preference)
