Taking care of someone with health problems can be hard. As a caregiver to a parent, spouse, partner, or even when looking after your own self, you may have to keep track of doctor visits, multiple medications, test results, paperwork, and more.
Medicare care coordination can help make things easier for caregivers and patients.
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What Is Care Coordination?
Care coordination means that doctors, nurses, and other healthcare providers work as a team. They share information, talk to each other, and plan care together. This helps make sure the patient gets the right care at the right time.
Without care coordination, there is a possibility that things may go wrong. A person might:
- Get the same test more than once
- Be given medicines that don’t work well together
- Have trouble getting follow-up care
- End up in the hospital when it could have been avoided
With care coordination, all the providers stay on the same page. That means fewer problems and better care.
Why Care Coordination Matters for Caregivers
As a caregiver, you already do a lot. You might help:
- Schedule doctor visits
- Talk to different doctors
- Manage medications
- Take your loved one to specialists
Care coordination can help make your job easier. Here’s how:
- Clearer communication: Everyone involved in care — doctors, nurses, and even the caregiver — gets the same information.
- Fewer repeated tests or mistakes: When doctors share notes, patients don’t have to redo the same tests or worry about medicine mix-ups.
- Better support after hospital stays: Medicare covers follow-up visits, phone check-ins, and help managing care at home.
- Help managing chronic conditions: A care team checks in regularly to help keep health problems like diabetes, high blood pressure, or heart disease under control.
Patient-Centered Medical Home (PCMH)
A Patient-Centered Medical Home (PCMH) is a type of doctor’s office where the team focuses on the whole person, not just one illness. The care is friendly, organized, and centered on the patient. In a PCMH:
- You get reminders for check-ups and shots
- The care team talks with specialists
- They help manage long-term health issues (like COPD or arthritis)
- They offer evening or weekend hours
- They help you find a coordinated care plan that fits your needs
PCMHs are especially helpful for people with chronic conditions because the team checks in often and keeps everything on track.
Accountable Care Organizations (ACOs)
An Accountable Care Organization (ACO) is a group of doctors, hospitals, and other providers who work together to provide coordinated care.
Here are some ACO benefits:
- Doctors can see your full medical history, test results, and prescriptions
- You avoid repeated tests and medicine mix-ups
- You may get telehealth visits (video appointments from home)
- You might not need a hospital stay before going to a skilled nursing facility
If your doctor is part of an ACO, they might have signs in the office stating so, or send you a letter about it.
How to Find a Coordinated Care Plan
Looking for coordinated care? Here’s how to get started:
- Ask your doctor if they’re part of a PCMH or ACO
- Request care management services like:
- Chronic Care Management (CCM) for long-term health problems
- Transitional Care Management (TCM) after a hospital stay
- Ask to work with a care manager to help plan care and stay organized
These services are often covered by Medicare, so don’t be afraid to ask.
Frequently Asked Questions about Care Coordination
- What is Medicare care coordination?
It’s when your doctors and care team work together, share information, and make a cohesive plan to give you better care.
- What does a care manager do?
A care manager helps schedule doctor visits, track medications, share info, and keep everyone on the same page.
- What are ACO benefits?
ACOs offer better communication, fewer repeated tests, telehealth options, and easier access to care after a hospital stay.
- How does care coordination help manage chronic conditions?
The care team checks in often, reviews medicines, and helps prevent problems before they get worse.
- How can I find a coordinated care plan?
Ask your provider if they’re in a PCMH or ACO, and if they offer care management services like CCM or TCM.