The Institute for Family Health
Like many providers, the Institute provides care coordination services through a number of programs that target special, underserved populations. Each of these programs operates with its own set of rules, staff configurations, and training requirements, and some patients that could benefit from care coordination services are not eligible. To improve efficiency and extend care coordination to all patients that could benefit, the Institute will develop a single model of care coordination that can be implemented across its network of sites. New care coordination teams will be formed, and standardized job descriptions and a core training curriculum will be developed. The new model will be piloted at several primary care sites. Patient outcomes and costs will be tracked to inform the fine-tuning and evaluation of the model. At the end of the project year, new sites will be targeted for the rollout of the model, with the goal of adapting the model for practices of different sizes and configurations. The Institute will share best practices and lessons learned with other providers.
Resources for family caregivers and health care providers are available at our Next Step in Care website.