Coordinated Care Management Framework

4. Implementation of Actions

  • Each member of the care team is responsible for the timeline and for implementing the action
  • Maintain contact with the patient and monitor for any changes, barriers, achievement of patient goals, implementation of actions and risk of readmission
  • Update coordinated care plan as required
  • Assess readiness to transition to new integrated care lead
  • Home/virtual visit as required

Resources

     

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