Care Coordination

“Continuing to think outside the box, because the box isn’t working for a lot of people” – In-home provider, US

“We check the patient’s data, knowing when they went to hospital; it has become easier for us and patients.” –CHW, India

“E-clinics give the same care as hospitals and time is saved.” – Administrator, India

“They didn’t use computers before and now they use it. And there is everything in there…the frequency we go to the health unit, the medication we take…” – Patient, Brazil

Care Coordination

A major emphasis of HealthRise programs in all sites was care coordination – linking different types of providers, various locations, and diverse information systems – to provide more efficient and effective care for patients. One key aspect of coordination was between clinic-based providers and in-home providers; information gained during home visits helped to improve clinical interactions, and in-home providers followed up with patients to reinforce recommendations from clinic-based providers and check in with patients who missed appointments. Largely through the use of frontline providers, care was also coordinated between traditional facility settings and mobile clinics, patients’ homes, and other settings in communities where screening camps, education sessions, and support groups were held. Through the development and creative of use of new technologies, patients’ data were linked across care settings and between visits, and providers were able to communicate with one another – this ranged from clinics in the US testing different EMR systems to CHWs in India filling HealthCards on mobile devices and communicating through WhatsApp, and SMS messages to facilitate communication with patients and the clinical support system in Brazil.

“I think the EMR resulted in a better way of communicating about the patient…any professional can now access the information stored in there.” – Frontline health worker, Brazil

“We need family health teams who would be able to link all the needs of the family to relevant programs. Community health care workers also need to be included.” – Frontline caregiver, South Africa

“A lot of what we did was design care coordination, work flows...we brought together the whole local health system...developing somewhat unique referral pathways and communication flows from referral clinics and partners...a closed loop back to our care coordination and clinic-based team.” – Administrator, US

“Having all these people at the table meant the needs of the patients were more readily met and ultimately…that built trust with the patient, everything improved, the patient came to the clinic more and was more up front about their struggles.” – Administrator, US

“Before the program, there was not much communication with the doctors and the nurses. Our work is usually with people from the community only. The HealthRise program has helped us in increasing our communication with officials at the clinic…Our rapport with doctors and nurses has improved.” – CHW, India

“They do the counseling, our work becomes easier, we just need to prescribe the meds.” – Trainer, India

“We work as a family, we help them in the areas they lack knowledge, sometimes they ask us outside of our working hours.” [on working with CHWs] – Clinic provider, India