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Care Coordination and Care Management
| Care Coordination |
Care Management Plus—People |
Care Management Plus—Technology |
| Identify & Assess Patient |
Referral to Care Manager (usually RN) & Protocol |
Algorithm to prioritize referrals & focus assessment |
| Co-Develop the Care Plan |
General + Disease specific protocols ; prioritization |
Protocols embedded in Tracking System; Patient worksheet |
| Communicate with All Relevant Participants |
Empowered self-management / navigation |
Tracking database for all communications |
| Monitor and Adjust |
Follow-up planning; incomplete components |
Reminders / tickler |
| Evaluate Health Outcomes |
Quality—achievement of health goals + control of disease; Efficiency—health system and societal |
Adapted from Closing the Quality Gap: Volume 7 Care Coordination
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