Reducing Barriers to Care: Care Coordination

PCMH practices:

  • Link patients with community resources to facilitate referrals and respond to social service needs.
  • Provide care management services for high risk patients.
  • Integrate behavioral health and specialty care into care delivery through co-location or referral protocols.
  • Track and support patients when they obtain services outside the practice.
  • Follow-up with patients within a few days of an emergency room visit or hospital discharge.  
  • Communicate test results and care plans to patients/families.