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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

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.

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

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

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

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

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

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

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.

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.

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.

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

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

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

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


  1. What is a case manager? Case Management Society of America website. 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.