To have the best outcomes, all agencies supporting individuals need to work together, sharing information and coordinating efforts to ensure people receive the best possible care. Doctors and nurses, public health professionals, school teachers, and other service providers should listen carefully to what people need, and how they prefer to receive support, and then communicate this information at the right time to the right agencies to ensure safe, appropriate, and effective care is delivered.
Care coordination includes prioritizing teamwork, using care managers, sharing health information appropriately, managing medications, and providing a patient-centered medical home.
Coordinating through a circle of care approach gives providers a common understanding of each person's needs and preferences.
It helps guide strategic planning to address social influencers of health. It allows providers to line up solutions that help each person achieve their full potential.
In a patient-centered medical home, people can receive all the care they need in one place. They don't have to travel from one doctor to another across town.
In a patient-centered medical home, all care providers work together to focus on the patient, and equip them to manage their own medical care.
Community health workers are people from your neighborhood. They are trained in basic public health information and then carry that information back to people in their own community.
They act as a bridge between their community and local public health agencies and service providers.