Glossary of Terms Care Coordination: The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. ( Agency for Healthcare, Research, and Quality) Care Coordinator: The person assigned to perform activities and interventions to insure the integration of patient care activities between two or more participants involved in a patient’s care to facilitate referrals and transitions and the appropriate delivery of health services. Care Management: A set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patient’s functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services. Clinical Information System: Effective chronic illness care is virtually impossible without information systems that assure ready access to key data on individual patients as well as populations of patients. A comprehensive clinical information system can enhance the care of individual patients by providing timely reminders for needed services, with the summarized data helping to track and plan care. At the practice population level, an information system can identify groups of patients needing additional care as well as facilitate performance monitoring and quality improvement efforts. Organize patient and population data to: Facilitate efficient and effective care Provide timely reminders for providers and patients Identify relevant subpopulations for proactive care Facilitate individual patient care planning Share information with patients and providers to coordinate care (2003 update) Monitor performance of practice team and care system
Glossary of Terms Care Coordination: The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. ( Agency for Healthcare, Research, and Quality) Care Coordinator: The person assigned to perform activities and interventions to insure the integration of patient care activities between two or more participants involved in a patient’s care to facilitate referrals and transitions and the appropriate delivery of health services. Care Management: A set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patient’s functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services. Clinical Information System: Effective chronic illness care is virtually impossible without information systems that assure ready access to key data on individual patients as well as populations of patients. A comprehensive clinical information system can enhance the care of individual patients by providing timely reminders for needed services, with the summarized data helping to track and plan care. At the practice population level, an information system can identify groups of patients needing additional care as well as facilitate performance monitoring and quality improvement efforts. Organize patient and population data to: Facilitate efficient and effective care Provide timely reminders for providers and patients Identify relevant subpopulations for proactive care Facilitate individual patient care planning Share information with patients and providers to coordinate care (2003 update) Monitor performance of practice team and care system
4_care_coordination_collaborative_change_package.docx