Care Delivery, Maintenance & Transitions
Care Delivery – Navigators
Navigators will work closely with the patient and family to coordinate the services that have been arranged and aligned, and will check-in with them on a regular basis to ensure that all is proceeding well.
The navigator will monitor the progress of the services and will follow-up directly if sufficient information has not been provided.
As the patient’s condition changes over time, the Navigator will again discuss with the patient and family the addition for other services that might not have been palatable in the early days. This would be a change to the care plan, so the Navigator will update the CCP , upload the new version to the Portal, and print a copy of the CCP for the patient and family.
If the care plan is not effective, or if the patient’s circumstances change, the Navigator may chose to bring the patient’s story back to Think Tank for further discussion.
As the patient’s circumstances settle, the Navigator may be able to reduce the frequency of check-ins, and possibly discharge the patient over time.
Care Delivery – Care Team Members
Service providers who are part of the Care Team should keep the Navigator up to date with how their services are progressing. At a minimum, each Care Team member should add a note to the patient’s record on the Portal:
- When patient has been contacted
- When service starts
- If service changes
- When service ends
In many cases, a monthly update on how things are progressing would also be helpful to the Navigator.
Care team members should use the portal’s secure messaging function to message the Navigator directly if concerns or questions arise about the patient and family.