Brigham and Women’s Hospital is committed to an interdisciplinary approach to managing patient care throughout the continuum. The Mission of Care Coordination is to coordinate the diverse aspects of patient care throughout the continuum of patient care to achieve the highest quality and most cost-effective outcomes. Care Coordination staff are deployed along major service lines: Cardiac Services, Emergency Department, Medicine, Primary Care, Oncology, Surgery, Neurosciences, Orthopedics, Thoracic Services and Women and Newborn Health. Care Coordination staff consist of Care Coordination Clinical and Administrative leaders, Social Workers, Care Coordinator Nurses and Resource Specialists.
The Department of Care Coordination responds to the medical management and psychosocial needs of all patients served by the Brigham and Women’s Hospital. Participation in network development with ECF’s (Extended Care Facilities) and homecare and community agencies is critical.
Provide care in an efficient and effective manner for each patient at any given time in illness and/or wellness
Establish and guide patient and family expectations
Manage care proactively in all settings and severity of illness, matching appropriate resources to the patient’s condition
Optimize resource utilization - family resources, community resources, provider resources
Enable patients and their families to become active, informed partners in the care and health maintenance
Focusing on preventative measures, preserve the patient’s health and optimize their health when not acutely ill
Contribute to improving care delivery
Care Coordination provides services that span the continuum of health care and is patient focused, timely, accessible, evaluated for improvement, based on ethical practice, respectful of patient rights, responsive to other care providers, current with insurers’ expectations and reflective of the evolution of health policy and medical practice.