Population Based Care Coordination

Care coordination has expanded over the last few years and continues to grow into a model that addresses the shift from strictly being focused on inpatients to that of expanding the concept to assuring that the person is in the right place at the right time for the right reason for the right cost. Greater emphasis is being placed on creating a model that will work in all settings and places the individual’s needs first. According to AHRQ, “Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.” Once again, right place, right time and right people are mentioned.

Thinking futuristically (not too far into the future) suggests that even care coordination should evolve into a more appropriately termed model called transitional care coordination that offers a seamless and smooth transition for the individual regardless of setting. Three important metrics that should be measured include: high-value care and high quality that provide improved outcomes for a person.

One aspect of care coordination (or whatever term you use in your organization) that is rarely mentioned is that traditionally a person who is receiving some type of service is called a patient. However, the term may no longer apply when one is receiving services along the continuum of care. Perhaps it is time to coin a new word or just say person or individual versus calling everyone a patient; something to think about during the initial phase of building the infrastructure to support a culture change.

A care coordination model should be evidence-based and built on protocols, standards of practice and quality guidelines from nationally recognized models and industry leaders, which may include familiarizing organizers with the Chronic Care Model as a starting point. Other groups that focus on coordination efforts may include Case Management Society of America (CMSA), the Commission for Case Manager Certification (CCMC) and most definitely the National Committee for Quality Assurance (NCQA).

Collaboration with internal stakeholders, particularly IT as well as community organizations and agencies is critical to shifting care coordination outside the four walls of the hospital. One cannot expect to improve care coordination efforts without IT and their understanding of data and the use of data analytics to capitalize on keeping populations healthy.

Start small. Care coordinators know the people in the demographic who use your services, thus combine data around a cohort that can benefit most from care coordination interventions.

Connect with patients and develop relationships; develop the relationship between a care coordinator and the patient with frequent communication that is initiated by the care coordinator and eventually communication becomes a two-way street to assure the person is in the right place at the right time. Patient’s voices must be heard, and they must be an integral part of decision-making. Personalizing care must happen.

Third party payers Since risk is being shared at higher percentages, an amicable relationship between health care organizations, providers and third party payers is essential. Such a relationship comes in handy during contract negotiations as well.

Monitor continual performance Developing meaningful metrics to determine progress remains a critical part of the infrastructure plan. Without these data, it will be similar to running in the sand; you will struggle to understand whether improvement in transforming your model is effective.

Stay focused and reassess your progress at various intervals. Engaging the care coordinators and asking questions that prompt thoughtful and meaningful discussions benefit the person who is at the center of the services being delivered. Assure that essential parties are at the table, particularly providers since the relationships that care coordinators have with providers is the linchpin that permits real success. Finally, it is no longer possible to case manage. Health care has morphed into a more comprehensive approach to the continuum of care; right place for the right person for the right reason at the right time for the right cost.