Who is really responsible for patient care? This question haunts many providers in the patient’s care but there is really no main individual who manages patient care. One of the best ways to help organize patient care is to organize a dedicated, multi-faceted, multi-disciplinary care coordination team.
An example of this model team would include a RN, physical therapist, occupational therapist, social worker, LPN, account rep and etc. The team of multi-disciplinary staff members will have the ability to coordinate referrals, communicate with physicians, patients and caregivers, communicate often with the client and effectively communicate well with other team members.
One of the most important abilities each team member must practice is the need to be proactive in problem solving and have the ability to motivate the patient and the patient’s caregiver. Along with developing strong problem solving skills, team members are responsible to effectively provide appropriate information such as assessments and case communications in a timely manner to identify at-risk patients to ensure the best clinical outcomes for them. It’s important to note that the team must have frequent in-person interactions with the patients in the first 15 days. Within this time frame, there is greater impact on the patient’s clinical improvement.
Utilizing the red and yellow flag system and creating action steps to react to certain situations with the patient will help to improve needed attention that may be missed with fragmented communication. The red and yellow flag system is designed to warn the care coordination team of critical health issues that can happen. The yellow flag symbolizes signs and symptoms with action steps that assist the patient to maintain their condition under control. During this stage, educate the team to recognize if the client needs additional resources such as a nutritionist or home care agency. The red flag alerts team members that the patient must take immediate action such as calling 911. The goal of this system is to catch everything that happens in the yellow flag stages to prevent red ones from occurring.
To learn more about how you can develop the Care Coordination experts in your agency that handle high risk patients, check out Complia Health’s white paper, Care Coordination: Improving Clinical Outcomes and Transitional Care.
About Complia Health, formerly Procura Healthcare SoftwareComplia Health is a leading global provider of technology and expertise for the long-term and post-acute care market. Nearly 3,000 home health, residential, community care, and hospice organizations count on Complia Health for the clinical, operational, and financial solutions required to profitability deliver quality care. Complia Health’s innovative products—including Procura, ContinuLink, Suncoast, Igea, and Progresa—are supported by a team of global health and technology experts located in the United States, Canada, and Australia. For more information about Complia Health’s products, click here.
