Care Coordination


Care coordination is part of care delivery, especially as it refers to coordinating and supporting the individual’s care and making sure there is a team leader for the person’s care needs. Successful care coordination depends on four essential, fundamental components:

  • Comprehensive, timely assessments and reassessments (at a minimum every 6 months; more often as warranted).
  • Coordination of decision-making across all settings of care and support.
  • Designated care coordinator with experience in working with persons with disabilities.
  • Member-centered care and support team, involving family, clinicians, and caregivers identified by the member.

Primary Care/Care Coordination Model Components

Following are some of the elements of the disability-competent DCP primary care/care coordination model:

1.                 Care Delivery

  • Enhanced primary care including interdisciplinary teams with shared decision-making, enhanced capabilities for comprehensive assessments, and home episodic care responses, with integrated durable medical equipment (DME), and mental health/behavioral health (MH/BH) services.
  • Availability of informed and knowledgeable clinicians with remote access to EHRs on a 24-hour, 7-day-a-week basis.
  • Early intervention strategies (consumer health literacy and training, clinical practice guidelines) to prevent complication or exacerbation of chronic conditions.
  • Inpatient care management with aggressive transition planning and follow-up.
  • Access to experienced providers, with training and interest in serving persons with disabilities, including open access to specialists
  • Revised provider payment to support increased time for primary care visits to reflect levels of complexity
  • Physical facilities that are truly accessible and have the necessary adaptive equipment.

2.                 Care Coordination

  • Comprehensive initial assessments and reassessments to identify member goals, needs, providers and services, leading to the development of an Individualized Plan of Care (IPC; also known as an Individualized Care Plan or ICP).
  • Coordination of decision-making across all settings of care and support, including behavioral health, work and social activities.
  • Designated “coordinator of care,” experienced with adults with disabilities and in managing care across all medical/clinical settings as well as in the community.
  • Member-centered care and support team, with involvement of family, clinicians and caregivers[i], in addition to the member.
  • Coordination team, modified to meet the unique needs of each member, consisting of any combination of a physician, nurse practitioner (or other advanced practice nurse), social worker, behavioral health clinician, occupational / physical therapist, and a durable medical equipment (DME) specialist.
  • Option for members to serve as their own care and services coordinator, or identify a family member or involved friend to coordinate care.
  • Online, integrated, comprehensive health care and support records accessible to and managed by the member and care coordinator, along with key involved professional and paraprofessional caregivers.

3.                 Consumer/Member Direction

  • Personalized Plans of care (also known as Individualized Care Plans or Individualized Plans of Care), incorporating individual health care goals and preferences, based on a functional assessment at a minimum of every 6 months.
  • Member involvement in management and/or governance, to provide participant/stakeholder input into programmatic and governance policy and direction.
  • Safeguards to eliminate institutional bias in the functional or financial eligibility criteria for long-term services and supports thus enabling members the maximum level of choice of setting and provider of care.
  • Dignity of Risk and Informed Decision-making, enabling and empowering members to develop, negotiate and implement plans to accept risk for and control of activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health maintenance activities.
  • Enhanced independence, via access to medically or functionally necessary DME and assistive technology (AT) and provision for immediate attention to repairs and/or replacements.
  • Expedited complaint resolution, as well as independent advocacy and appeal processes to address consumer needs and concerns.
  • Educational support for members to function as full healthcare partners