PATIENT INTRODUCTION TO ENHANCED CARE COORDINATION
Policy:
All Lake Superior Community Health Center (LSCHC) Enhanced Care Coordination (ECC) patients will have an introductory discussion with a member of his/her care team about the Enhanced Care Coordination program, participation objectives, and expected outcomes.
Procedure:
Provider
1. Providers, collaboratively with patients and families, determine if a patient qualifies for or is interested in HCH participation, and if so gives the patient a copy of the Health Care Home brochure.
2. The provider explains the ECC based on the following context: “Our ECC program is an approach to helping you be as healthy as you can be. It is a team approach in which we partner with you to help you meet the health goals that we will create together. All of our staff is committed to working as a team with you to help you be healthy. It means talking with someone or getting an appointment when you need to. It means working together to help you manage your health concerns. It means helping to coordinate any care that you might get elsewhere – like the hospital, emergency room, or specialists. We want to know you, and we want you to know us so that we develop a long term relationship for your good health.”
3. The provider also explains the benefits of participating in the ECC to the patient:
a. A team approach to help the patient improve their health with the patient’s input.
b. Participation in managing their care through a partnership of the Enhanced Care Coordination care team and the patient and their family.
c. Creating and following a care plan specific to their needs
d. Coordination of health related services
e. Having an advocate (Health Care Home Coordinator) to ensure they get the best care possible
f. Improve health care outcomes
4. The provider answers any questions the patient may have regarding participation requirements, their role/commitment, financial implications and how the ECC process works.
5. If the patient agrees to participate in ECC, or is interested in further information, the provider flags the Health Care Home Coordinator in the EHR system via referral or desktop, or verbally tells the Health Care Home Coordinator. This referral indicates that the provider and patient discussed ECC, and the patient agrees to participate or wants to learn more about the program.
6. During the initial visit when ECC is discussed, the provider documents the ECC discussion with patient in patient medical record.
7. The provider becomes the key member of the patient’s health care home team and works with the patient, the Health Care Home Coordinator and other team members to maintain the Care Plan and monitor the patient’s progress.
Health Care Home Coordinator
8. The ECC Care Coordinator makes introductory call to patient providing information about ECC including:
a. The role of Enhanced Care Coordination within the Health Care Home
b. The name of the patient’s responsible primary clinician
c. The responsibilities of team members including the patient’s and clinic’s team members
d. The role of the care coordinator
e. The clinic’s office hours
f. How to access the clinic after hours
g. Referral coordination services, referral sources and access procedures
h. What is new and different from the coordination previously received
i. Payment method
j. The voluntary nature of ECC
9. If the patient agrees to participate, the Health Care Home Coordinator will:
a. Change the patient banner to both notate participation in the medical record and add him/her to the registry.
b. Establish the MDH Tier.
c. Schedule a follow up appointment with patient to develop care plan if the patient is Tier 3 and above or wishes to have one .
10. If patient declines to participate, the Health Care Home Coordinator or MA will change the patient banner to “declined” and develop a plan for reevaluation in the future.
Date Initiated: April 2013
Next Review: April 2016, Medical Director
Lake Superior Community Health Center
Patient Introduction to Enhanced Care Coordination Page 2 of 2
Medical - Clinical