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.
Benefits of Coordinated Care
Effective population health management benefits patients, physicians, health care organizations, the entire health care system, and the nation at large. Here’s how:
- Patients receive better coordinated care – and enjoy better health – because they are reminded of procedures needed to manage their condition or disease.
- Physicians are better informed and their patients are more engaged, resulting in better outcomes in care. Physicians also more easily satisfy quality measures that focus on engaging patients and providing timely, appropriate, coordinated care.
- Health care organizations are more profitable – whatever their payment model – because gaps in care are filled, patient volume increases and the cost of delivering care can be more accurately quantified.
- The nation benefits from reduced health care costs, better management of diseases, and a generally healthier population.
Examples Of Care Coordination
- 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 challenge of caring for a rapidly aging America. 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.
- 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 nature of their condition. Because emergencies like strokes and heart attacks can happen anytime, 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 providers are involved, making it even more important that health care be 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.
- 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.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.
Successes and failures in care coordination will be perceived in different ways depending on the perspective: patient/family, health care professional(s), or system representative(s). Consideration of views from these three potentially different perspectives is likely to be important for measuring care coordination comprehensively.