Care Coordination
This page provides tips and best practices from grantees on care coordination.
California: California developed strategies to decrease the wait list for appointments, defer work that is completed by the neurologist that could be taken care of by another member of a team, improve communication with primary care providers, and provide families with information and education enabling them to better understand their child's diagnosis and ongoing care:
1. Provide quarterly training to primary care providers to allow for improved communication and coordination of care and to equip the primary care providers with an improved understanding of treatment options, criteria for referral and medication management.
2. Enter in a Service Agreement with Ambulatory Clinics and large community pediatric practice groups to define in writing, referral criteria, methods for assuring ongoing communication.
3. Hire a Pediatric Nurse Practitioner (NP) to oversee follow-up appointments with return patients and to provide assistance to neurologists to decrease the time they are required to spend with new and/or returning patients.
4. Hire a Health Educator, part-time, to provide education and training to families on keeping a notebook, understanding their child's condition. Parent evaluation data were critical to provide the justification for this position. Parents reported poor satisfaction with the level and amount of education /training they received.
5. Social Worker will provide support to the families in accessing community services and supports, again helping to reduce the amount of time the neurologist is required to spend with families on non-medical issues.
6. Extend visit intervals based on patient needs, not on a standard return policy, e.g. quarterly or semi-annual appointments. This was facilitated by updating the discharge form, adding a section, in which the neurologist can identify when the next visit is needed. Prior to this, all visits were scheduled for the same intervals.
7. Schedule return appointment prior to the patient/family departure from the clinic instead of waiting and scheduling 3 months prior to the appointment. Previous practice was only to schedule 3 months in advance, families were asked to call back for follow-up appointments 3 months prior to projected date.
8. Implementation of the Patient Access Center at the Children's Hospital (Specialty Care, purpose was to track referrals from primary care to specialty care and provide follow-up to families) improved the Epilepsy Center's ability to follow-up with neurology referrals. The volume of referrals increased dramatically when implemented but settled to a more manageable amount. The Center improved the Epilepsy Center's ability to accurately assess the pool of new referrals waiting for a first appointment.
