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Care Coordination: the Backbone of the Integrated Delivery System

There are thousands of healthcare and social service providers in the Bronx, and each one is committed to giving Bronx residents the best care possible. Yet no person or organization alone  an satisfy every need of every patient. Whether it is accessing the results of a diabetic patient’s most recent A1C test, connecting a woman suffering from severe depression to a psychiatrist, or stabilizing housing for an elderly man with heart disease, providers must work together constantly to coordinate care.

Getting coordinated care right means learning what each patient needs to be healthy, connecting them to the right services, and making sure they are following through with their treatment. It means helping providers reach the patients who need them most.

However, coordinating care is not always easy; it takes time to manage a patient’s many needs, and may require new IT infrastructure to share information more efficiently. Not every provider can overcome these hurdles, and when there is a hole in the care coordination process – when any one provider is excluded from this system – every provider and every patient suffers. BPHC’s strategy for healthcare reform involves standardizing systems of care coordination across our PPS and across the Bronx.

Our providers will gain access to care coordination staff, some of whom will support the highest risk populations, for whom care coordination is not a matter of convenience but of necessity. Care coordination staff will utilize new technologies to share information about their patients. Community-based organizations (CBOs), which play an indispensable role in addressing the social determinants of health, will be included in this care coordination process and in the broader Integrated Delivery System.

Building the Bridge Between Projects

A year from now, a man will visit the emergency room because he is having an asthma attack. He will speak with a patient navigator in the ED, who will reach out to an a.i.r. bronx community health worker, who will meet him at home to help him manage his asthma symptoms, medication, and triggers, and even hire an exterminator because roaches at home make his asthma worse. A care coordinator, embedded within the man’s primary care team, will guide him to the healthcare and community services that he needs to stay healthy. Care coordination is what ties BPHC’s projects together.

Each BPHC project is targeted, focusing on improving services that are heavily utilized in our community, like hospitals, primary care practices, behavioral health, and social services. These projects have also been carefully designed to intersect with and reinforce one another, because there are multiple social and medical factors at play in every person’s health. BPHC will need to seamlessly guide patients from one project to the next – to coordinate their care across projects – to fully manage their health and everything affecting it.