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Slide Presentation from the AHRQ 2007 Annual Conference

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Care Coordination and Care Management

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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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