Tai Paquin, LADAC
| 1. Have clients faced barriers such as communication difficulties or lack of transportation that hinder their healthcare needs? | Yes | No |
| 2. Have there been instances where services or efforts provided to clients were duplicated? | Yes | No |
| 3. Are there concerns about medication management? | Yes | No |
| 4. Has there been uncertainty about the status of DME or IPT requests? | Yes | No |
| 5. Do clients attend PCP but have trouble following up on referrals or care recommendations? | Yes | No |
Integrated care coordination models have been gaining headway in the healthcare arena as a method for improving patient outcomes, creating efficient processes, reducing healthcare costs, and addressing challenges associated with health systems. To determine whether this model could be valuable within your clinic, it may be helpful to consider if any of these scenarios noted above have been experienced in your clinic. And if they have, care coordination may be something to consider.
Delivering effective healthcare in tribal communities involves more than just administering medical treatment; it requires culturally appropriate, community-focused support that aligns with the distinct needs of American Indian and Alaska Native (AI/AN) populations. Care coordination plays a role in this process by helping to bridge the gap between medical and behavioral health services, thus ensuring comprehensive, patient-centered care.
Care coordination involves organizing the patient’s health care activities among medical and behavioral health providers to effectively address all their health needs. Important components include facilitating communication to ensure all providers are informed about diagnoses, treatments, and progress; managing transitions to support patients as they move between different care settings, such as from inpatient services to primary care; and addressing barriers by assisting patients with challenges like transportation, medication adherence, or health-related stigma.
Many tribal communities experience both physical and behavioral health issues, including conditions such as depression, diabetes, or substance use disorders. Without a higher level of support, such as care coordination, these conditions may go untreated or exacerbate one another and may show up in clinics as crisis or emergency situations. To address this, a collaborative approach in healthcare can lead to early interventions that reduce the frequency of emergency visits and improve the management of chronic conditions. Additionally, this approach can provide holistic and culturally sensitive care, which enhances patient satisfaction and overall health outcomes.
An article by Dwyer, et al. (2022), titled “Provider Communication: The Key to Care Coordination Between Tribal Primary Care and Community Oncology Providers” discusses this role of care coordination in tribal healthcare settings. Specifically, in areas where access to specialists has its challenges, the article emphasizes that effective coordination between primary care providers and [oncology] specialists is essential for managing [cancer] care. This collaboration forms a core component of integrated care models developed to support tribal communities. The article goes on to highlight the importance of clear communication and information sharing to make sure care is smooth and patient-focused, especially for populations with higher needs.
With the unique obstacles that most tribal health systems face, such as geographic isolation and resource challenges, building strong coordination relations is even more essential. In integrated care models, healthcare providers from various disciplines, such as primary care, behavioral health, and social services, collaborate to develop care plans that address the unique needs of patients.
According to the article, by establishing positive relationships within care teams and through effective communication networks, it is possible to improve patient outcomes, minimize gaps in care, and elevate the standard of health services provided. This strategy aligns with the overarching objective of BH integration, which aims to deliver an integrative, coordinated system of care between behavioral health and primary care providers.
In summary, understanding how care coordination can be implemented within your tribal clinic is a valuable consideration. Care coordination is an approach that addresses service gaps and barriers, to ensure integrated, patient-centered care. And, by improving provider communication and managing transitions, tribal health systems can improve patient outcomes, reduce breakdowns in care, and deliver equitable healthcare. A future presentation will dive deeper into a related concept of comprehensive case management, exploring its role in integrated care settings to better support tribal members.
Article Reference
Dwyer, K., Anderson, A., Doescher, M., Campbell, J., Wharton, B., & Nagykaldi, Z. (2022). Provider Communication: The Key to Care Coordination Between Tribal Primary Care and Community Oncology Providers. Oncology nursing forum, 49(1), 21–35. https://doi.org/10.1188/22.ONF.21-35