Organisation Domains

 

Care coordination drivers describe the ecosystem in which the CC&TH service operates.

These drivers take into account the coordination of care, the organizational structure & function, technology, and care pathways.

Care provider coordination

The interaction and information exchange with the patient and between all care providers

A good infrastructure for information exchange is needed to coordinate patient care between all involved care providers.

Examples

  • Care providers coordination: the information exchange and alignment between care providers. What is the degree of integration of processes?
  • Primary care: the ability to coordinate activities with primary care.
  • Patient experience: the introduction of the CC&TH service to the patient
  • Legal alignment: what is the legal status of the CC&TH service? What is the clinical accreditation status?
  • Financial alignment / incentives: the funding structures and reimbursement model for the CC&TH service.

 

Organizational structure & function

Describes how CCTH services are embedded in the organization

The context in which the CC&TH service operates varies from region to region. A good characterization of the context is needed to explain differences in outcomes between regions.

Examples

  • Legal alignment: what is the legal status of the CC&TH service? What is the clinical accreditation status?
  • Financial alignment / incentives: the funding structures and reimbursement model for the CC&TH service.
  • Organization: staff, roles, authorization, responsibilities, and data ownership
  • Administration efficiency: connection between the CC&TH service and local processes to avoid duplications and make the best use of available resources.
  • Evaluation: is the performance of the CC&TH service regularly evaluated?

 

Technology

Considers the technology support behind the CCTH service

Characteristics and performance of the CC&TH technology affect the usability of the service for patients and care givers.

Examples

  • Role of ICT services: How ICT services are embedded in CCTH
  • Interoperability: Technology support for data exchange
  • Organization & management: coordination of IT orders and purchase
  • Service level agreements: Formal agreements on the performance of the service

 

Care Pathways

Considers how the CCTH service is structured and provided to the patient

Information exchange and interaction with the patient are believed to be crucial for better outcomes

Examples

  • Standard: existing protocols or guidelines for chronic disease management for CC&TH services for COPD, diabetes and HF specifically.
  • Multi-morbid: support for multimorbidities in the care pathways.
  • Programs: content of the disease management program.
  • Interventions: the means to detect and intervene when a patient deteriorates or has special care needs.