Comagine Health’s Partnership to Reimagine Health Care is part of a national initiative to improve care for people with Medicare while reducing provider burden and cost. We’re working together with long-term and post-acute care providers, health systems, hospitals, primary care and specialty providers, community organizations, and patients and their families to the transform health care system.
Why Care Coordination is Important
Care coordination is the process of organizing a patient’s care across multiple health care providers. Without coordination, care can become fragmented. Fragmented care occurs when health care providers don’t communicate effectively with each other around a patient’s care. This often results in repeated lab tests, medication mismanagement, errors and other issues. This can lead to high emergency department (ED) utilization and readmission rates. This increases the burden on both the patient and the larger health care system.
Fragmented care results in increased cost for both patients and health care systems. Comagine Health is providing training, tools and resources for health care professionals and other key stakeholders across the industry that will help strengthen care coordination, improve patient health outcomes and result in cost savings for both health care systems and patients.
Who Needs Care Coordination?
- Patients recently discharged from the hospital who require follow-up appointments.
- Individuals with multiple chronic conditions that require coordination between primary care providers and multiple specialists.
- Patients who formerly received home-based services and have recently been admitted to skilled nursing facilities.
- Patients negatively impacted by social determinants of health (SDOH). This includes individuals who experience issues with accessing reliable housing, transportation, food and other basic needs. These individuals require coordination with community health workers (CHWs) and/or social service agencies.
- Care Transitions From Hospital to Home: IDEAL Discharge Planning (AHRQ)
- Creation and Implementation of a Pharmacy-Led Meds-to-Beds Program at a Large Teaching Hospital (Journal of the American Pharmacists Association)
- The 8P Screening Tool Identifying Your Patient’s Risk for Adverse Events After Discharge (SHM Project BOOST)
- Ottawa Hospital Research Institute LACE Index Scoring Tool for Risk Assessment of Death and Readmission (Great Plains QIN)
- Innovation at Its Best: Medication Reconciliation (Institute for Healthcare Improvement)
- CMS Framework for Health Equity 2022–2032 (Centers for Medicare & Medicaid Services)
- Transitional Care Management Services (Medicare Learning Network)
- Chronic Care Management Services (Medicare Learning Network)
- FAQs: Advance Care Planning Under Medicare (Coalition for Compassionate Care of California)
- Annual Wellness Visit Brochure (Medicare Learning Network)
- Telehealth and Libraries: A Perfect Pairing (Arizona Telemedicine Program)
- Community Paramedicine Models for Post-Discharge Follow-Up Care (Rural Health Information Hub)
- Guide to Reducing Disparities in Readmissions (CMS)
- The EveryONE Project Neighborhood Navigator (Search for financial assistance, food pantries, medical care and other free or reduced-cost help)
New Mexico Resources