Patient Care Coordination
Overview
Patient care coordination is a key strategy that has the potential to improve the effectiveness, efficiency, and safety of the healthcare system. Patient level data is captured and harnessed strategically to improve patient care.
Care co-ordination provides an expanded form of HIV medical case management, including:
- Ensuring that people living with HIV infection are linked to care in a timely manner.
- Developing a patient-centred care plan that emphasises continuous adherence to care and antiretroviral treatment.
- Assisting patients in obtaining needed social services, including accompanying patients to appointments if necessary, and maintaining patients in care via navigation of medical and social services.
- Using care coordinators to assist patients with accessing HIV care, communicating with providers, and finding needed resources. (Bradford et al.)
- Coaching (a form of active health promotion and counselling) patients to become self-sufficient so that they can manage their medical and social needs autonomously.
Use Cases
The use cases for patient care coordination include:
- viral load monitoring,
- linkage to care and
- treatment interruption monitoring .
These use cases inform the minimum datasets necessary to supplement the components needed for an effective program monitoring and patient care coordination at the patient and facility level. The analysis of this data is carried out at the facility level and aggregated to form part of the facility analysis. The visual representation is done using dashboards and other reporting tools, and all this with the overall goal of improving HIV outcomes.
