1. Delivering Coordinated Patient Care State of Reform Health Policy Conference
Donald J. Rebhun, MD, MSHD National Medical Director
DaVita HealthCare Partners
November 6, 2015

2. What Is Care Coordination?
Sylvia
Care management components:
Patient engagement
Comprehensive assessments
Care plan development
Medication reconciliation
Advance care planning
Patient education
Self-management
Proper use of/access to network, providers, and services
Care coordination
Tracking of referrals to other providers or settings of care
Test tracking (laboratory, radiology, and other diagnostic procedures)
Admission and discharge planning
Follow-up appointment tracking
DME and home/community-based service needs
Information transfer/communication among providers and care settings
Difference between care coordination and care management:
Care coordination is a component of care management just like medication reconciliation or patient education or care plan development are.
Care management is the concept of taking care of a population of patients across all settings and collaborating with all providers, including community based ones. Can include one or multiple programs depending on population, needs, etc. and would involve not just case managers but also PCPs, Specialists, Pharmacists, Social Workers, etc.
Care coordination includes activities like managing/tracking appointments, labs, ordering supplies/DME, scheduling home health, referrals to specialists and other providers, placement, community based services.
Care  management is the strategy to reduce costs and increase quality. Care coordination is one of the tactics.
Patient-centered
Assessment-based
Interdisciplinary approach
Improving Health Status
Reducing Patient Cost
Team Based Care

3. Intervention Action Items
One Patient Care Plan
ONE
Care Plan
Goals
Intervention Action Items
Medications
List of Providers/ Contact Information
Advance Care Plans
Patient Preferences

4. Where are the Opportunities?
Preventive Health
Ambulatory Care Management
Quality gaps
Chronic Conditions
Diabetes, Heart failure
Respiratory/COPD/Asthma
Behavioral health
Care Transitions
Transitional Care Management
Care coordination/navigation
Utilization Management
Focus Areas

5. Patient-Centered, Coordinated Care Delivery
Primary Care
Physicians
Wellness &
Health
Enhancement
Programs
Specialists
24/7 Patient
Support
Center
Patients
& Families
Hospitalists
Care / Disease
Management
Coordinated IT
Infrastructure
Programs not in traditional FFS
Built to care for patients with chronic conditions