The Navigating Care Coordination Series provided physicians and their teams an enriched, cross-discipline group learning experience focused on testing new approaches in care coordination. Participants focused on reducing patient care gaps and delays while improving information flow between primary and secondary/tertiary care. Primary care practices worked closely with a referral partner (e.g. regional health authority programs, consultant physicians, community programs, etc.) serving a shared patient population to build a care coordination agreement. The agreement was tested and optimized with existing healthcare team members and implemented within their practices.
By the end of this program, participants should be able to:
- Discuss the current state of care coordination in NL;
- List available resources relating to care coordination;
- Create a list of common terms linked to care coordination;
- Describe high-impact changes for care coordination and seamless transitions;
- Synthesize patient stories and experiences of care coordination in the codesign of care coordination agreements;
- Coordinate with a referral partner to test and implement care coordination change ideas within their primary and specialty practices using the model for improvement;
- Develop a care coordination agreement between referral partners;
- Explain how care coordination affects continuity and, subsequently, patient care and safety;
- Share their experiences within the navigating care coordination learning series community about the opportunities and challenges to improve care coordination;
- Describe to other practices and healthcare partners how they have successfully applied QI within their practice to improve care coordination;
- Write a team action plan to sustain and spread care coordination improvements within their practices;
- Demonstrate the value of celebrating improvement successes with the referral partnership team.