Existing Care Coordination Programs

Patient-Centered Medical Home: An Overview

Care Coordination Wellesley

“When we were told we would be able to get a Care Coordinator, somebody who could solve all these little problems to prevent bigger problems, we were thrilled.”
— Denise Mayo, MD  Primary Care of Wellesley

Healthcare is too complex for one single provider in the modern day; it needs a team to succeed.

Physicians will now have a team that helps them work with the patient, and understand what the patient needs. The physician now has someone who can facilitate his treatment plan, and the patient has an advocate that helps them navigate in the healthcare system.


Role of the Care Manager

Care Coordination Wellesley2

“….I have to discharge someone who is sick, and complicated, and lives alone, and can’t drive to get to his doctor’s appointment. I am reassured by knowing that there is a care manager, who as soon as I discharge them, will be on the other side, waiting to help facilitate their care.”  — Namita Seth Monta, MD


Care Coordination in Ontario, Canada

A care coordination program in Canada. Unlike other care coordination programs, the care coordinators here pays visit to the patients and report their conditions to care providers.

They transition patients from hospitals and assist them in regaining independence.

This program targets high risk populations in a community setting. Keeping people in their homes, so there is more room in the hospital for people who actually need to be in the hospital. These care coordinators go as far as doing home assessments for the patients. Taking care of what happens after patients are discharged.


The Future of U.S. Healthcare Part II: Care Coordination is the Key to Sustainable Healthcare

“The role of the Care Manager is a new one at many physician practices. The job of the care manager is to think about patient needs other than what is provided right in the office. These can be social services, transportation services, medication reminders–whatever it is that a complex patient might need in order to remove barriers to high quality care, and to landing themselves in the hospital.”