This blog post was written for Center for Health Innovation and Implementation Science at IU School of Medicine,while I was a Strategic Digital Communications intern back in 2018-2019.
Care Coordination is a hot topic in the healthcare industry right now, particularly when it comes to value-based care. According to NEJM Catalyst (2018) – “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 making sure that care from disparate providers is not delivered in silos, and to help reduce health care costs by eliminating redundant tests and procedures.”
A care coordinator shared what happened when she consulted with a patient who was causing frustration for the physician and the pharmacy. This patient was always running out of her medication and would keep calling the office or her pharmacy repeatedly.
When the coordinator first met with her, the patient was skeptical. It took time to develop their relationship. The patient had several health issues and a weak social support system. Eventually, she started bringing her medication to the clinic. She was not taking it correctly, which explained why she was always running out of her drugs. Another problem was literacy – the medication instructions were confusing to her – and part of the issue was anxiety around her health.
The care-coordinator began to meet with her every week. The patient and coordinator agreed that she would bring her medicine in, and the care-coordinator filled her pill organizer. In the beginning, the coordinator would fill it every week while the patient watched her. Over time, she taught the patient to fill her medicine box while she supervised, making sure she did not have any trouble. After four months, the patient was taking her medications as prescribed and no longer ran out of them. What was interesting to note was that there was a dramatic drop in her emergency room visits.
So what changed for this patient? Was it that she received the kind of support she needed? Was it about educating her about her medication? Was it that the care coordination team could identify other contributing triggers, such as her mental health, which led to connecting her with behavioral health resources? Or was it that all members of the care team – clinicians, pharmacists, and other providers – were collaborating and transparently communicating on the treatment of this patient? It was all of the above that made a difference.
To truly impact patient outcomes, care coordination has to start before the care team is in place. It should begin with the patient. For any healthcare organization to be successful, care coordination needs to become individualized. One needs to look beyond the data to see how healthcare costs can be improved, how engagement can be increased, and how satisfaction could be enhanced. It is all about putting the patient population at the center of care coordination.
Healthcare organizations should assess and understand the populations they are serving before strategies can be developed and plans put into place. One needs to asses the community and know what the needs are. Then comes the goal setting. There are many ways to implement a care coordination strategy, know your organization and the population it serves to identify gaps in care, and the most significant opportunity to make a difference.
Care coordination addresses some common challenges faced by healthcare organizations such as high readmission rates, using emergency service in place of primary care, and discouraged patients because of the complex healthcare system.
Healthcare organizations should, therefore, look at two significant areas to improve with a comprehensive care coordination strategy.
- Implement a grassroots care coordination strategy: which involves reaching out to patients, trying to engage with them face to face, and via telephone outreach to develop trust relationships with them to get to their underlying problems.
- Data transparency and communicating with the care team: Care coordination requires data transparency and interoperable systems. When healthcare technology is not interoperable, it makes communication between care team members difficult, which can be detrimental to the patient experience. Moving into a single interoperable EHR, for example, can empower outpatient care coordinators, social workers, the ER utilization management team, clinicians to better collaborate and be transparent across the care continuum. That is value beyond measure.
Life Is Like That! 