Population Based Care Coordination


Care coordination synchronizes the delivery of a patient’s healthcare from multiple providers and specialists.  Faith Jones, the Director of Care Coordination at HealthTechS3, has 30 years of healthcare experience in various settings, including ambulance, clinics, hospitals, home care and long term care.  Collaborating with HealthTechS3 and implementing a turnkey Care Coordination program, our clients achieved better care for individuals while reducing healthcare costs.

For more information on HealthTechS3’s Care Coordination program, contact Faith Jones faith.jones@healthtechs3.com

Care coordination has expanded over the last few years from a primarily inpatient model to one that ensures each person is in the right place at the right time for the right reason for the right cost. According to the Agency for Healthcare Research and Quality (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.”

Thinking into the future suggests that 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. Important metrics that should be measured include high-value and high-quality care that provide improved outcomes for a person.

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).

A few key points to follow are addressed below:

  • 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.
  • Care coordinators know the people in their demographic who use services, thus combine data around a cohort that can benefit most from care coordination interventions. Develop the relationship between a care coordinator and the patient with frequent communication initiated by the care coordinator and eventually communication becomes a two-way street. Patient’s voices must be heard, and they must be an integral part of decision-making. Personalizing care must happen and it will occur at the right time.
  • 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 this data, it will be difficult to understand whether improvement in transforming your model is effective.

In summary, stay focused and reassess your care coordination program progress at various intervals. Engaging the care coordinators and asking questions that prompt thoughtful and meaningful discussions benefit the patient who is at the center of the services being delivered. Assure the appropriate stakeholders are involved, 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.