Care Redesign

What Is Care Coordination?

Article · January 1, 2017

Care coordination synchronizes the delivery of a patient’s health care from multiple providers and specialists. The goals of coordinated care are to improve health outcomes by ensuring that care from disparate providers is not delivered in silos, and to help reduce health care costs by eliminating redundant tests and procedures.

What is care coordination?

Care Coordination Process. Click To Enlarge.

Four Elements of Coordinated Care

Successful care coordination requires several elements:

  1. Easy access to a range of health care services and providers
  2. Good communications and effective care plan transitions between providers
  3. A focus on the total health care needs of the patient
  4. Clear and simple information that patients can understand

Examples of Care Coordination

Health care providers are implementing coordinated care throughout the entire continuum of care, from primary care to long-term care. The following examples show how care coordination is stenghtening all levels of care by introducing many of the elements of successful care coordination.

1. Primary Care Coordination

To care for patients with chronic diseases and conditions such as diabetes and high cholesterol, some providers have adopted a “guided primary care” approach. The Guided Care model was developed by a team of researchers at Johns Hopkins University, to respond to the growing challenge of caring for a rapidly aging America.

In the Guided Care model, a specially educated, registered nurse (RN) is responsible for patients with multiple chronic conditions. The RN performs an initial assessment with the patient, works directly with the primary care providers to develop a care plan, and coordinates specialty care with other providers to ensure that nothing is missed and the plan is followed.

In one study, Guided Care was shown to decrease total health care costs by 11%, with an average net annual savings of $1,364 per patient for health insurers. In another Guided Care study, Lahey Health in Massachusetts credits Guided Care with achieving a significant reduction in hospital readmissions.

2. Acute Care Coordination

Patients with acute health problems like a stroke or heart attack require a more complex level of care due to the critical and emergency nature of their condition. Because emergencies like strokes and heart attacks can happen anytime, anywhere, patients may first receive care by emergency medical services and by hospitals outside of their regular network. The risk for communication breakdowns, redundancies, and medical errors can increase when disparate providers are involved, making it even more important that health care be synchronized and coordinated to achieve the best clinical results. Studies show that acute care coordination focusing on communication between provider-handoffs is an important factor for success.

Acute care coordination continues when the emergency has passed and the patient is discharged from the hospital. Acute care coordinators confirm proper transition of care by scheduling follow-up visits, making sure prescription medications are filled at the patient’s pharmacy, and reviewing follow-up instructions with the patient and his or her family or loved ones. They also will follow up with patients a few days after they leave the hospital to check on their progress and answer questions. The goal of these efforts is to help reduce hospital readmissions rates, prevent avoidable ER visits, and contribute to a reduction in mortality rates.

3. Post-Acute/Long-Term Care Coordination

Patients who reside in rehabilitation, long-term care (LTC) or post-acute care (PAC) facilities may need to move between facilities — or to different care levels within facilities — as their health changes. An AHA study found that “a majority of patients admitted to PAC are later transferred to a second PAC setting.” These predominantly senior-aged patients often have mental and memory disorders in addition to physical ones. They therefore require coordinated care to manage medications transfers and update care plans. The importance of this is increasing as studies show that “hospital discharges to post-acute care (PAC) facilities have increased rapidly” and “hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.”

With successful models, care coordinators — in many cases licensed social workers — work with patients and their loved ones to ensure everyone understands the care plan and related expectations. They also act as patient advocates, providing referrals to support services available through their facility or through other organizations, to help ensure the patient has the best quality of life possible.

The Current State of Coordinated Care

An NEJM Catalyst Care Redesign Insight Report found that health care organizations are adopting coordinated care practices at varying rates.

Care Experience Coordination Post-Acute Care

Care Experience Coordination. From the Care Redesign Insights Report. Click To Enlarge.

  • 7% said their patients’ care was fully coordinated between the various health care settings.
  • 30% said care was mostly coordinated.
  • 53% said care was somewhat coordinated.
  • 10% care was not coordinated.

As health care providers continue to implement coordinated care initiatives, challenges remain, including lack of uniformity in coordinated care models and the need to address patient concerns that their physicians are “not talking to each other.”

Care coordination is a team sport in many ways. For health systems to successfully coordinate care, they must have the proper infrastructure, resources, leadership, and culture to support synchronized efforts, communication, and collaboration among multidisciplinary teams of providers and specialists.

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