Table 1. Existing models for care... | American Society of Hematology

Table 1.

Existing models for care coordination

Model	Population	Description	Goal	Resource type
Cancer navigator model¹⁹	Patients with cancer	Four key areas in which navigators help:	Provide 1 person to have continual involvement throughout the cancer care process and remain present in follow-up and reassessment care as a safety net for patients	Trained layperson
		Social support
		Decision-making processes
		Active coping
		Self-efficacy
		Patient navigator begins with an in-depth assessment to understand a patient’s challenges, navigation needs, and current levels of social support
Veterans Health Administration care coordination/home telehealth model²¹	Rural and transportation-challenged patients	Designed to provide noninstitutional care to the >30% of beneficiaries who live in rural locations	Deliver cost-effective, flexible way to extend care beyond the traditional visits to brick-and-mortar clinics, with a heavy reliance on patient self-management	Nurse/social worker
		Technology varies:
		Video phones
		Messaging deviceS
		Biometric devices
		Telemonitoring devices
		Active case management while monitoring patient data for signs of health deterioration requiring immediate care
Virtual integrated practice model²²	Chronic and complex conditions	Virtual communication technology as the foundation to support 4 key strategies for achieving patient care goals:	Cross–care team collaboration with heavy emphasis on patient self-management	Entire care team
		Planned communication
		Process standardization
		Group activities
		Patient self-management
Chronic care model¹⁸	Chronic conditions	Adoption of 6 system changes, includING:	Achieve patient-centered, evidence-based care	Nurses/social workers
		Patient self-management support
		Provider decision-making support
		Delivery system design patient and population clinical information systems
		Health care organization and community resources
Primary care medical home/patient-centered medical home²⁴	Primary care	Partnership among practitioners, patients, and families	Achieve patient-centered, comprehensive, and coordinated care	Entire care team
		Care for physical and mental health needs, including prevention and wellness, acute care, and chronic care
		Coordinated care across all elements of the broader health care system
		Increased accessibility and strong communication through health IT innovations
		Commitment to quality and safety
Oncology medical home⁵	Oncology patients	Care coordination	To improve population health, enhance the patient experience, and reduce costs by coordinating care and standardizing the care process	Oncology practices
		Integrated electronic medical record
		Patient education
		Standardized documentation
		Telephone triage system
		Performance metrics
CMS oncology care model⁶	Oncology patients	Care coordination	Improve care and lower costs through an episode-based payment model that financially incentivizes high-quality care	Physician practices
		Payment and delivery models		Commercial payers
		Navigation
		National treatment guidelines for care

Model	Population	Description	Goal	Resource type
Cancer navigator model¹⁹	Patients with cancer	Four key areas in which navigators help:	Provide 1 person to have continual involvement throughout the cancer care process and remain present in follow-up and reassessment care as a safety net for patients	Trained layperson
		Social support
		Decision-making processes
		Active coping
		Self-efficacy
		Patient navigator begins with an in-depth assessment to understand a patient’s challenges, navigation needs, and current levels of social support
Veterans Health Administration care coordination/home telehealth model²¹	Rural and transportation-challenged patients	Designed to provide noninstitutional care to the >30% of beneficiaries who live in rural locations	Deliver cost-effective, flexible way to extend care beyond the traditional visits to brick-and-mortar clinics, with a heavy reliance on patient self-management	Nurse/social worker
		Technology varies:
		Video phones
		Messaging deviceS
		Biometric devices
		Telemonitoring devices
		Active case management while monitoring patient data for signs of health deterioration requiring immediate care
Virtual integrated practice model²²	Chronic and complex conditions	Virtual communication technology as the foundation to support 4 key strategies for achieving patient care goals:	Cross–care team collaboration with heavy emphasis on patient self-management	Entire care team
		Planned communication
		Process standardization
		Group activities
		Patient self-management
Chronic care model¹⁸	Chronic conditions	Adoption of 6 system changes, includING:	Achieve patient-centered, evidence-based care	Nurses/social workers
		Patient self-management support
		Provider decision-making support
		Delivery system design patient and population clinical information systems
		Health care organization and community resources
Primary care medical home/patient-centered medical home²⁴	Primary care	Partnership among practitioners, patients, and families	Achieve patient-centered, comprehensive, and coordinated care	Entire care team
		Care for physical and mental health needs, including prevention and wellness, acute care, and chronic care
		Coordinated care across all elements of the broader health care system
		Increased accessibility and strong communication through health IT innovations
		Commitment to quality and safety
Oncology medical home⁵	Oncology patients	Care coordination	To improve population health, enhance the patient experience, and reduce costs by coordinating care and standardizing the care process	Oncology practices
		Integrated electronic medical record
		Patient education
		Standardized documentation
		Telephone triage system
		Performance metrics
CMS oncology care model⁶	Oncology patients	Care coordination	Improve care and lower costs through an episode-based payment model that financially incentivizes high-quality care	Physician practices
		Payment and delivery models		Commercial payers
		Navigation
		National treatment guidelines for care

CMS, Centers for Medicare and Medicaid Services; IT, information technology.

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