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Care Navigation | Care Transformation Framework: Linking Care to Community
Care navigators can help facilitate transitions as patients — particularly those with chronic or complex diseases — move from the acute care to home setting while remaining connected to needed outpatient services.
Patient and Community Engagement | Care Transformation Framework: Linking Care to Community
Through formal and informal processes (e.g., community health needs assessments, patient and family advisory councils, community-based programs, partnerships) hospitals receive guidance on how they can better connect with individuals of all backgrounds.
Telehealth Resources | Care Transformation Framework: Community Settings
Telehealth programs expand access to care so that people can conveniently receive medical advice and treatment no matter where they are located.
Provider Partnerships | Care Transformation Framework: Linking Care to Community
By fostering partnerships across providers as part of a clinically integrated network, health care organizations can better facilitate coordinated care for their patients.
Primary Care Transformation | Care Transformation Framework: Linking Care to Community
Health systems are transforming primary care to provide holistic care that closes care gaps while prioritizing prevention and managing complex health and social needs across the continuum of care in alignment with new payment models.
Alternate Care Sites Resources | Care Transformation Framework: Community Settings
Innovative health care organizations are designing services to meet people where they are — in community settings such as the home, community-based clinics, schools, retail clinics, etc. This encompasses post-acute, specialty, ambulatory and primary care.
Integrated Behavioral Health Resources | Care Transformation Framework: Clinical Settings
Mental and physical health are intertwined. Having mental health professionals on the care team leads to better, more holistic care for patients.
Coordinated Resources | Care Transformation Framework: Foundational Principles
Partnerships across health care professions, industries and sectors allow hospitals to foster an environment that is conducive to improving health. Community stakeholders and patients are key partners in codesigning new care delivery models.
Technology-enabled Care Resources | Care Delivery Transformation Framework: Clinical Settings
Technological advances are applied to care delivery to improve patient care and ensure that patients receive the right care at the right time.
Policies and Procedures Resources | Care Transformation Framework: Operational Infrastructure
Underlying all these operational components, health care organizations have policies and procedures in place to advance their mission as they decide where to devote their financial and staff resources.