The kids have soccer practice at two different schools today. Ok, you take one and I will take the other to practice. Great, how will they get home from practice? How long is practice? Text you later once we have the details.
This is a simple example of coordinating drop off and pick up. Sounds like a normal conversation in most homes.
Now let’s use a different example and coordinate care for an elderly patient who takes several medications and needs to send test results from the hospital to their coordinating physician.
Scenario: A vibrant parent has been hospitalized twice in the past few months, but is struggling home alone. Our hospitalized parent is like most and still wants to have a car for independence. We need a schedule a follow up visit with the doctor to review the recent hospitalization. Plus, our patient needs a plan for getting well.
How does all this information get coordinated?
The best way to get better is for the family to be involved and for the care to be coordinated with patient data. What caused the hospitalization? What happened in the hospital – were medications prescribed? Lab results? Diagnosis? Care plan to wellness? And of course, how is the family and care team helping?
Centralization and access to all patient health information (PHI) is step one. All patients entering the hospital get discharge planning. Next, the cell phone numbers and contact information of family members should be added, and finally, what support can be expected when the family is NOT available?
Who is responsible?
Coordinated care plans should be shared with the entire team – patient, family and healthcare team. Then, a schedule is adhered to. Text, email and phone call reminders with reports are mandatory.
Coordinated care is about bi-directional communication. 7am is coffee and fruit. 9am is medicine with food. 11am is walking with friend. 1pm is medicine again. 3pm is afternoon checkup. 5pm is dinner and meds with family. 7pm grandchildren check-in and 10pm news and bedtime.
Who is accountable?
Every step has a phone call, text, email and confirmed report for all team members. This is coordinated care with data!