DVACO Care Coordination: Supporting Primary Care

The Care Coordination department launched in the fall of 2014, with the addition of the Director of Care Coordination, Ann Marks, RN, who brings over 25 years of experience within payer and provider sectors serving special needs populations. In October 2014, the DVACO added two of its first RN care coordinators, who have since assisted over 500 patients with complex care needs. The DVACO’s care coordination team works with patients in collaboration with their primary care providers, specialists, hospital-based care managers, practice-based care coordinators, and a multitude of agencies, in an effort to reduce fragmentation of patients’ care. Our care coordinators complement existing care coordinators within the health systems’ employed practices or other ambulatory settings. Our goal is to serve as an extension of the primary care providers’ staff.

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As the DVACO evolves, we seek ways to improve patient care. This requires utilizing experienced care coordinators who are primarily registered nurses or social workers, along with standardized processes for identifying patients within the population who are most likely to benefit from enhanced care coordination. Technology to support a standardized care coordination process is imperative, and includes patient identification, stratification, data analysis, care planning, alerts about gaps in care, and documentation of the overall care coordination process.

A key component of the quality measures we use to evaluate the success of care coordination is continuous monitoring of emergency department utilization and inpatient hospital admissions rates. DVACO also helps monitor the patient’s transition of care from hospital to nursing home or home health, as well as to and from the patient’s own home setting. This includes evaluation of access and adherence to prescribed medications, scheduling of followup appointments, and assessment of patient barriers to recovery. Our care coordinators then develop a care plan with the patient and primary care provider to help track the identified problems, goals and interventions.

The DVACO Care Coordination department welcomes the opportunity to meet with providers and organizations to discuss the care coordination program. A secure email and toll-free number have been established for practices or facilities to refer a DVACO patient for evaluation of care coordination needs. Email us at Carecoordrefer@dvaco.org or call 1-855-598-4225.