Care Coordination

CARE ACROSS THE CONTINUUM

What is Care Coordination?

care_coordinationBSWQA has a team of Health Coordinators and registered nurse Care Managers that support Patient Centered Medical Home (PCMH) and value-based contract goals for our physician members of the Baylor Quality Alliance.

Care coordination services extend the PCMH capabilites.  Here’s how:

  • RN Care Managers provide nursing assessments for your high risk patients between PCMH visits
  • Health Coordinators provide patient and PCMH outreach to reduce gaps in care and support wellness goals

What services does Care Coordination provide?

  • Transitional care
  • Health status assessment
  • Medication reconciliation
  • Navigation to primary care physician
  • Transmit relevant inpatient/ED records to primary care physician
  • Disease management
  • Navigation to primary care and other health care resources
  • Medication reconciliation
  • Health coaching
  • Goal setting
  • Self-management training

Patient communication letters explain why BSWQA Care Managers are contacting your patient.