Domain 3: Team-Based Communication
When individuals see more than one provider or utilize services within multiple health and community systems, coordination and communication can be a challenge. Essential to effective Holistic Care Coordination (HCC) is establishing and following plans to assure that everyone on the care team is timely, efficient, respectful and culturally sensitive.
Work as a team.
- Pick a lead. All teams need a leader and care coordinators can be the key to maintaining strong communication among the care team (see Standard 3.1 for more information).
Work with the family.
- Family MUST inform all decisions. The family is the center of the care team and decisions should align with the family's beliefs, strengths, values and aspirations. (see Standard 3.2 for more information).
- Relationships are key. Care coordinators should develop and maintain positive relationships with patients and families (see Standard 3.7 for more information).
- Flexible for family needs. Families can change care coordinators at any time, so it's important to have a plan to transfer responsibilities as needed (see Standard 3.8 for more information).
- Support the family. Care coordination support should be accessible through all members of the care team (see Standard 3.9 for more information).
Communicate with the family.
- Make communication easy. Communication should match the individual's, or family's, preferences; consist of a single point of contact, such as the care coordinator; and make optimal use of electronic tools (see Standards 3.3, 3.4, and 3.6 for more information).
- Materials developed for families. Materials provided to families should be culturally appropriate and be written at proper literacy levels (see Standard 3.5 for more information).
Communicate with other providers.
- Coordinate with other care coordinators. Policies and procedures for care coordinators to identify and coordinate with any other care coordinators serving the individual (see Standard 3.12 for more information).
- Maintain regular communication. Utilize electronic tools to remain in regular, timely and efficient communication (see Standard 3.10 for more information).
- Communicate with community-based organizations. Care coordinators should communicate with, and refer to, community-based organizations to address additional needs (see Standard 3.13 for more information).
Evaluate care coordination services delivered.
- Assess family role. Assess that the family is informing decisions and that the team is operating in line with the family's values, beliefs, strengths and aspirations (see Standard 3.2 for more information).