Coordinated Care Planning

Information for Primary Care Providers

Coordinated Care Planning

Multiple providers, appointments and complex care issues can make it difficult to met a patient's unique needs. A more collaborative approach to care can be achieved through Coordinated Care Planning.

Bringing together multiple providers, the patient and his or her informal supports enables the development of a care plan that best supports the patient goals and needs.

Primary Care can lead or participate in this collaborative approach to care, which seeks to:

Further the optimal model of primary care that is based on a continuous patient-provider relationship, coordinated services across the health system, and a high-level of access and equity in the delivery of services;
Provide greater care coordination for patients that providers worry about the most;
Strengthen linkages and relationships among care providers to support the delivery of primary care that is truly person-driven;
Ensure that patients with complex needs receive integrated and coordinated care;
Designate a lead coordinator within the patient’s care team to help organize various healthcare services and supports;
Document a shared care plan focused on patient's goals;
Reduce avoidable office visits, ED visits and hospital admissions, as well as the utilization of other services that reduce continuity of care, such as walk-in clinics

To discuss Coordinated Care Planning for individuals across the South West:

Call 1-855-371-6337

For individuals who need Home and Community Care Services (South) and Coordinated Care Planning, please complete a referral form

For more information, documents and tools click here