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Reducing Care Fragmentation - A Toolkit FOR Coordinating Care
Improving Chronic Illness Care and MacColl Institute for Healthcare Innovation created the Chronic Care Model, which summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels. One of the primary goals of care coordination efforts is a high-quality referral or transition. This Toolkit summarizes the elements that contribute to successful referrals and transitions, which include: Assuming accountability, Providing patient support ,Building relationships and agreements among providers and Developing connectivity via electronic or other information pathways. The tool is available as a PDF, requiring Adobe Reader to view the document.