Care Coordination

In 2017, Dignity Health sought to improve and standardize its care coordination efforts by creating an enterprise-wide approach to care coordination. We worked with ambulatory physicians, nurses, care coordinators and other stakeholders across Dignity Health and employed various tools and evidence-based research to design a standardized structure and approach to care coordination.

The goal of care coordination is to help the patient regain or maintain optimum health or improved functional capability that best serves the patient.

Co-Chairs: Gail Daly (System), Gail Moxley (System), Jamie Davis (System)

Care Coordination Patients

Care Coordination Physicians

About the Program

Under Dignity Health’s new care coordination model, patients are evaluated and then placed into one of four categories based on a specific set of qualifying parameters. Each category includes corresponding services and best practices that care coordinators can use to provide care for each individual.

The athenahealth Population Health platform assists with risk stratification of Dignity Health’s patient population. This helps our care coordinators to identify potential candidates, access social determinants of health, enroll patients in disease management programs and document patient interactions. It also helps them make evidence-based medical care decisions while concentrating resources where they can do the most good for the overall population.

Dignity Health Transfer Center

Though its physical location is in Sacramento, the Transfer Center is able to advance a coordinated, systematic, and customizable approach to serving those with acute, chronic and complex conditions by providing leading transfer and consult services. These services help create coordinated and continuous patient journeys and maximize access to the best care available. The ranges of services include: Acute transfer and consults, System telemedicine, Patient placement, Post-discharge placement.

In October 2017, the Dignity Health Transfer Center began its system standardization process, operationalizing all of its markets. The Transfer Center’s reach now includes the service areas of Sacramento, Southern California, Arizona, North State and the Bay, as well as three pending service areas: Bakersfield/Central California, Central Coast and Nevada.

The Transfer Center adds value by:

Achievements

Large-market completed transfers by service area in FY18

Humankindness lives here.

From Hope to Home

When Sandra* was sent to short-term rehabilitation after surgery for a hip fracture, her world fell apart: During her stay, her husband passed away and her daughter committed suicide. As a result, she became depressed, stopped participating in therapy and “just wanted to die.” At the request of the rehab facility’s administrator, Dignity Health’s Care Coordination team worked to find resources to offer her support during a time of crisis for the purpose of healing mind, body and spirit. They were able to connect with a local hospice partner who provided a licensed clinical social worker for support. The licensed clinical social worker made medication recommendations to the attending physician, met with Sandra and encouraged her to ease back into therapy, after which she was eventually able to return home.

*Name has been changed to protect patient privacy.