Case Coordinator Program

Introduction

A case coordinator is a healthcare or human services professional who Actively communicate, share clear information and collaborates with the family and the community in providing health care services.

One of the main measures adopted by the Ministry of Health is the model of care. It was introduced as part of the new vision of our country (2030) in 2017. The model represents a method for restructuring health care through interactions between health systems and communities. It focuses on the patient's journey through health system and help to provide an organized, coordinated, and patient centered healthcare services. The outcomes of this model will be reflected on cost reduction, decrease in morbidity and mortality from chronic diseases as well as increase the satisfaction of patients and their caregiver.

We in the chronic care team are working together to improve chronic diseases care in the region that integrate the available resources with the best practices worldwide. We will also engage the healthcare workers at different healthcare levels to activate the role of multidisciplinary team in the management of chronic diseases.

Roles and Resposibilties

Arrange scheduled appoints and periodic health examination.
Track defaulters.
Communicate with patients and other providers to coordinate service.
Track referrals.
Arrange and follow-up patients referral to hospitals, emergency medicine departments and feedback.
Coordinate interactions between providers that will help patients have better continuity of care.
Sharing of information about all aspects of patient care.
Manage and ensure patient visit care plan, and schedule visits.
Follow-up on appointment, lifestyle, and medications with progresses.
Documenting follow-up plans (recording dropouts, and completers during follow-up).
Collect and analyze process performance measure.
Record health care plan for each patient.

Scope of services

Case coordination will involve continuing care services: community based services, home care services, primary care, secondary care, and tertiary care services, across the public and private healthcare sectors.

Communication Framework

Policy & Toolkit

Assessment

Management

Request

Information