Model Care Coordination Agreement for Primary Care-Hospital Care TeamCare Coordination Agreement • August 18th, 2017
Contract Type FiledAugust 18th, 2017If admission³ directly initiated by PCP: Discuss case with HCT member on duty in preparation for admission Provide demographics Patient name, DOB, and contact information Contact person if not patient e.g. healthcare proxy or guardian Any special considerations required such as vision/hearing impairment, cognitive deficits, language/cultural preferences PCP designation, referring provider, contact information Provide reason for hospitalization Primary complaint/medical issue/assessment and diagnosis Relevant notes, key physical findings and/or test results as well as summary of recent changes in status Any co-morbid conditions that will need attention during hospitalization Prepare patient/family/caregiver Ensure there is understanding of and agreement with planned hospitalization Ensure safe transfer to the appropriate facility in manner that takes into account patient preferences Provide hospital contact information and expected time frame for hospital length of stay For any hospital