Care Coordination

Abstract

AbstractCare coordination provides a framework to deliver quality care to the most complex and high-risk patients while simultaneously controlling resources and cost, particularly at the end of life. Through assessment and exploration of the social determinants of health, social workers can address barriers to shared decision-making; in turn, this boosts healthcare communication with the ultimate goal of improving care and health outcomes. A social work–led care coordination called the Ambulatory Integration of the Medical and Social (AIMS) model is presented through four areas: (1) patient engagement, (2) assessment and care plan development, (3) care coordination, and (4) care as needed. However, care coordination has not traditionally incorporated palliative care assessment and interventions. Models that integrate routine care coordination with palliative care can enhance effective healthcare service delivery. Health social workers have unique expertise to lead teams in implementing and engaging in care coordination activities that provide services and support patients, families, and caregivers.