Improve Patient Outcomes With Better Care Coordination

Picture this:  A patient returns to your facility from a hospital stay. The security officer hands you a cursory after-visit summary that barely scratches the surface of what occurred during the hospitalization. It leaves you with more questions than answers about the patient’s condition and health care needs. Does this sound familiar?

How about this:  You finally receive a fax from the hospital with all the records from the patient’s hospitalization, but it is over 100 pages of data, notes, and test results that you must sift through to determine the necessary ongoing care and follow-up.

These examples are just two of the many challenges related to care coordination that you may have encountered in your day-to-day work.

Ensuring appropriate, timely, and comprehensive care for incarcerated patients is complex, to say the least. It becomes even more complex when off-site services are involved and when health care needs to be aligned across multiple teams of clinicians.

It’s not just correctional health professionals who face these challenges⁠—the community health professionals involved in delivering these services face them too. Consider a surgeon who recently operated on an incarcerated patient who doesn’t understand why the patient didn’t show up for their scheduled post-op visit. Or a triage nurse who’s handed a perfunctory emergency transfer summary about the patient who just showed up in handcuffs.

The nuances of providing health care in a jail or prison⁠ are often unfamiliar to clinicians who work outside of the correctional setting. Yet, nearly all of them have patients who are incarcerated at some time.

As health care professionals, we all play a role in care coordination⁠—that is, “the intentional organization of patient care across multiple participants, accompanied by the sharing of relevant information, to improve the safety and effectiveness of services.”1

Enhancing our skills in this area and having open discussions with colleagues about optimizing care across different health care settings can be beneficial for all of us.

In light of this, the NCCHC is launching a three-part webinar series dedicated to enhancing the coordination of care for incarcerated patients. This is a concerted effort to unite clinicians from correctional and community settings, aimed at improving the care of our mutual patients.

The first webinar will focus on building effective collaboration between on-site correctional health care teams and off-site community health care providers, covering patient hand-offs and effective information sharing.

The second webinar will address the specific challenges involved in coordinating care during emergency department visits and hospitalizations.

Finally, the third webinar will concentrate on patients with complex medical conditions that often involve numerous specialists and episodes of care.

Our hope is that you come away from this webinar series feeling like you are part of a cohesive care team⁠—even if that team is physically divided across multiple health care settings.

Reference:

1. Albertson EM, Chuang E, O’Masta B, Miake-Lye I, Haley LA, Pourat N. Systematic Review of Care Coordination Interventions Linking Health and Social Services for High-Utilizing Patient Populations. Popul Health Manag. 2022 Feb;25(1):73-85.

By: Sylvie Stacy, MD, MPH, CCHP-CP, YesCare. Dr. Stacy is the chair of the NCCHC Education Committee.

Webinars:

On-site and Off-site Health Care Team Collaboration
February 29, 2024
12 pm Pacific / 3 pm Eastern
More Information/Register

Coordination of Care: Emergency Department Visits and Hospitalizations 
March 14, 2024
11 am Pacific / 2 pm Eastern
More Information – Coming Soon

Coordination of Care for Complex Medical Conditions 
March 28, 2024
9 am Pacific/12 pm Eastern
More Information – Coming Soon