Thomas ME
Professional case management. Date of publication 2008 Jul 1;volume 13(4):220-7.
1. Prof Case Manag. 2008 Jul-Aug;13(4):220-7. doi:
10.1097/01.PCAMA.0000327412.24720.c7.
The providers' coordination of care: a model for collaboration across the
continuum of care.
Thomas ME(1).
Author information:
(1)YRMC Home Care Services, Prescott Valley, AZ 86314, USA. methomas@yrmc.org
OBJECTIVE: With guidance from Health Services Advisory Group, the Arizona
Medicare Quality Improvement Organization, a Prescott, Arizona, workgroup
consisting of a hospital, nursing home, and 2 home health agencies have come
together to improve continuity of care as related to pressure ulcer prevention
and treatment.
METHODS: Weekly, then monthly, meetings were held to develop recommendations for
practice standardization, a treatment grid for easy reference, an educational
module with posttests, and standardized physicians' orders, which were developed
and disseminated to the local provider community.
RESULTS: More than 200 staff members were educated at Yavapai Regional Medical
Center (YRMC), local skilled nursing facilities, and home health agencies. In
addition, new employees and nursing students are now educated on the Providers'
Coordination of Care Educational Module at YRMC. The Module has been placed on
the hospital's Web site and offered free to all interested parties.
IMPLICATIONS FOR CASE MANAGEMENT: With pressure being mounted by Centers for
Medicare & Medicaid Services, the Office of the Inspector General (OIG), and the
general public, the role of the case manager (in all practice settings) will
increasingly become more crucial. Through development of a network of local
venues of care, the case manager can facilitate care transitions throughout the
healthcare system with the goal of improved outcomes for the patient regardless
of setting. Providing the right care, in the right setting to improve patient
care, can only benefit our aging and declining populations.
CONCLUSIONS: Cross-setting work will become more essential as the Centers for
Medicare & Medicaid Services goal of pay-for-performance is realized across all
care settings. As a national priority, pressure ulcer prevention and treatment
needs to be embraced by all settings. It serves the patient, as well as the
healthcare providers, to improve care regardless of setting or competition.
Positive results can be accomplished if the best interests of the patient are
kept at the forefront. To this end, obstacles of competition and individual
facility possessiveness must be overcome to achieve the desired results. Having
the right mix of professionals will enhance the results. The lessons learned here
can be used in any across-the-settings initiative.
DOI: 10.1097/01.PCAMA.0000327412.24720.c7
PMID: 18636007 [Indexed for MEDLINE]
