You are here

Enhance Care Coordination

The coordination and delivery of care are the central pillars of patient case management, which the Case Management Society of America defines as a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs.1,2

Below are a number of resources designed to help healthcare teams devise and implement proper care coordination for patients with cardiovascular disease (CVD). Included are tools to help enhance communication among healthcare providers (HCPs) providing care to patients with atrial fibrillation (AF) who are at risk of stroke, and evidence-based guidelines and performance measures endorsed by leading organizations that address the ongoing care coordination needs for patients discharged after deep vein thrombosis (DVT) or pulmonary embolism (PE).

14 resources available

AF Care Coordination Checklist

Step-by-step checklist for review when considering transitioning patients from one site of care to the next, to help ensure that appropriate information is shared among healthcare professionals, patients, and their caregivers.

View Resource

Cost of Stroke Among High-Risk AF Patients

Hypothetical look at AF patients and stroke risk when anticoagulant use is increased by 10%.

View Resource

DVT/PE Transitions of Care Kit

An interactive resource guide to support improved care coordination for patients discharged after a DVT or PE.

View Resource

Get the Facts on AF

Patient-oriented information about AF, including symptoms, stroke risk, and tips for working with their healthcare team.

View Resource

Guidelines and Performance Measures for Venous Thromboembolism (VTE) Treatment and Care Coordination

Select performance measures and recommended guidelines for treating VTE and preventing recurrence.

View Resource

Management of AF-related Stroke

Facts about stroke risk in patients with AF, and a synopsis of guidelines for thromboprophylaxis.

View Resource

Managing VTE Risk in Knee and Hip Replacement

Overview of VTE risk-reduction strategies at each stage of a knee or hip replacement procedure—from preoperative planning through the postdischarge period.

View Resource

Optimizing the Role of the Care Manager

Provides insights into the health risks of patients with VTE and explains the role of the care manager in delivering effective follow-up care for these patients.

View Resource

Optimizing Transitions of Care for VTE

Describes VTE risk, from the perioperative and hospital phases to discharge and possible readmission, highlights potential intervention points and barriers, and suggests improvements for each phase.

View Resource

Postdischarge Follow-up 

Discusses guidance from the National Transitions of Care Coalition (NTOCC) and the Agency for Healthcare Research and Quality (AHRQ) on initial and ongoing follow-up as well as suggestions for encouraging patient adherence to their treatment protocols.

View Resource

Postoperative Follow-up and Care

Offers case managers tips for preparing for a follow-up call to patients after knee or hip replacement surgery.

View Resource

Stroke Prophylaxis in Patients with AF

Overview of guideline recommendations for thromboprophylaxis and for effective care transitions.

View Resource

Transitions of Care Checklist

Provides suggestions for discharge planners and case managers should discuss with patients and their caregivers to support a successful transition from the hospital.

View Resource

VTE Process Flow in Orthopedic Surgery Patients

Illustrates each phase of the VTE prophylaxis flow (perioperative, hospital, discharge, and readmission) to prompt discussion about intervention points that support appropriate VTE prophylaxis.

View Resource
Get Adobe Reader

Janssen tools and resources have not been proven to improve outcomes and may not completely address the specific intervention activities listed on each page. Janssen tools or resources discussed should be evaluated against other available sources of information before decisions are made about how to approach patient care within your organization. Full descriptions of appropriate use and associated limitations are set forth in the respective tools and resources.

This information has been developed by Janssen Pharmaceuticals, Inc., and made widely available to support patient and provider education.

References:

  1. What is a case manager? Case Management Society of America website. http://www.cmsa.org/who-we-are/what-is-a-casemanager/. Accessed June 13, 2018.
  2. Yamamoto L, Lucey C. Case management “within the walls”: a glimpse into the future. Crit Care Nurs Q. 2005;28(2):162-178.