Primary Care - Fraser Health

Care CoordinationSupporting family practices with casemanagement for complex conditions“Many clients are elderly and isolated. They are so pleasedwith this intervention and feel much more in control. Weprovide the time and resources necessary, including makinghome visits, to thoroughly assess the whole patient situation,and quickly make the right connections for them within ourcomplex system.”– Nancy MacDonald, Care Coordinator,iConnect Health Network, White Rock-South SurreyPrimary care providers can help patients navigate various services in the system with greater easeand efficiency, using care coordination services provided in the iConnect Health Network.What is its purpose?Care coordination services help physicians, patients and families navigate health care services moreeffectively by:• Coordinating continuity of care between multiple providers and services.• Ensuring all necessary connections are made and followed up.• Ensuring all relevant information is documented, exchanged and updated.How does it work?• Currently, there are plans to establish Care Coordinators in all three iConnect Health Networkcommunities – White Rock/South Surrey, Surrey and New Westminster.• Care coordination is available for patients with multiple, complex needs; for example, a frail elderlyperson with co-morbidities who requires a number of services.• Physicians send referrals for these patients to the Care Coordinator. Under direction from the GP, theCoordinator plans and organizes treatment, services and providers.• Feedback and progress reports are provided to the GP to ensure the patient’s care plan is on trackand needs are met.• Care coordination used in Fraser Health is based on international evidence-based models.… continued on reverse →PC.04.21.09