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Care Coordination | Value-Based Care

Value-based Care Solutions: Care Coordination to Engage Patients

October 24th, 2023 | 5 min. read



Content Team

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Three approaches have converged to improve clinical outcomes, elevate the quality of care, and decrease barriers that stand in the way of patient-centered healthcare. They are:

  • Patient engagement tools, techniques, and efforts have prioritized shared decision-making and collaborative efforts between people and providers to make healthcare less top-down.
  • Care coordination to manage the complexity of an increasingly fragmented healthcare system and advocate for patient access.
  • Value-based care incentivizes providers to take greater responsibility for care quality, cost, and outcomes.

Today’s continuing shift to home-based and post-acute care sites, coupled with greater adoption of value-based care arrangements—like patient-centered medical homes, accountable care organizations, and advanced primary care—reinforces the critical need for robust care coordination and patient engagement.

Care coordination is foundational to value-based care

At a time when inefficiency in the US healthcare system wastes up to 25% of spending, care coordination has become a go-to strategy to streamline service delivery.

Value-based care functions best when a provider or payor organization is responsible for the overall value of care delivered, as well as its outcome.

Using a team-based approach, care coordination carries out several activities fundamental to value-based care, including:

  • Help patients and families navigate the healthcare system
  • Support transitions of care between facilities or specialists
  • Establish care plans built on shared decision-making
  • Provide patient monitoring and follow-up to avoid readmissions or complications
  • Connect patients with support and community resources
  • Facilitate communication among the care team, including patient and family caregivers

A sophisticated care coordination program equips a healthcare organization to enter into value-based care contracts and two-sided risk arrangements.

Care coordination’s importance to value-based care

Care coordination provides vital links, continuity, and consistency that drive efficiency. It can enable collaboration within and across care teams and the patient, which is critical to achieving value-based care objectives.

Research has revealed the value of care coordination:

  • Enhancing disease management outcomes: One study showed that care coordination helped 56.2% of patients achieve D5 goals in diabetes A1C control, improving outcomes by 97.2%.
  • Reducing cost: Coordinated care was found to reduce costs for patients by nearly 50% compared to more fragmented care across the healthcare ecosystem.
  • Increasing adherence and meeting patient preferences: The Agency for Healthcare Research and Quality found that care coordination can lead to better commitment and alignment with patient preferences while achieving greater safety and appropriate utilization.
  • Lowering readmission rates: Research shows that care coordination reduces 30-day readmission rates.

Care coordination and patient engagement go hand-in-hand

Patient engagement has become a clinical standard in healthcare settings, quality improvement, and performance measurement. 

Focused on patient‐centeredness, empowering self-management, shared decision‐making, and partnership, patient engagement is a primary objective of care coordination.

When implemented within a team-based, value-based care arrangement, these approaches become a powerful combination toward efficient, high-quality care.

For example, SMART goals and motivational interviewing are two tools that care coordinators can use to collaborate with patients. They can help patients take proactive steps to improve health that account for life context and potential barriers to achieving goals.

Technology, like care coordination software, makes important data, activities, and history accessible to everyone. This supports patients and clinicians to make better decisions together, ensure consistent follow-up, and avoid gaps in care or miscommunication.

The benefit of care coordination and patient engagement within value-based care is that the services needed to achieve improved outcomes can be incentivized and adequately compensated. 

Value-based care programs offer accountable reimbursement and incentives that support advanced programs and interventions. For example, at Cleveland Clinic and Geisinger, care coordination and patient engagement performance are linked to salary models. At Geisinger, these provider incentives accounted for up to 20% of total compensation.

Patient engagement grows with care coordination results

Patients inevitably perceive fragmented care as failures by their provider and care team. This can erode trust and investment in care plan adherence. Missteps are perceived as mistakes rather than an outcome of a disjointed system.

On the other hand, healthcare professionals also witness failures when a patient is directed to the least effective channel. Or, when there’s a poor health outcome due to inadequate handoffs or information sharing.

By creating a team facilitated by a care manager, led by a physician, and supported by various clinical and social roles, care coordination can maximize patient engagement while streamlining care delivery and providing more person-centric support.

How ThoroughCare can help

ThoroughCare can help providers collaborate and deliver digital care coordination. Our platform can help: 

  • Streamline the creation of patient care plans 
  • Support staff workflows with guided, validated assessments
  • Help motivate patients through clinical recommendations and SMART goals
  • Analyze patient risk factors and generate clinical recommendations
  • Identify behavioral health conditions
  • Monitor key performance metrics to spot gaps in care
  • Track and log services for an audit-proof record of care

Additionally, ThoroughCare supports comprehensive integration with leading EHRs, health information exchanges, remote devices, and advance care plans, while helping providers visualize and interpret patient and operational data through analytics

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