Care coordination includes organizing patient activities and services across multiple providers. The approach prioritizes communicating all relevant information to the participants involved in the person’s care. Its overall objective is to fulfill an individual’s care needs and preferences through high-quality, personalized engagement.
According to the Centers for Medicare & Medicaid Services (CMS), a “lack of coordination can lead to negative health outcomes for patients, more use of emergency care, medication errors, poor transitions of care from hospital to home, and medical errors.”
There are two primary approaches to achieving coordinated care: broad strategies that are commonly employed to enhance healthcare delivery and specific care coordination activities.
Broad approaches involve:
- Chronic Care Management
- Medication adherence and management
- Team-based care and collaboration
Specific activities can include:
- Assessing patient needs and goals
- Developing comprehensive care plans
- Coaching and educating patients to support self-management
- Advocating for patients and connecting them to community resources
- Addressing social determinants of health (SDOH)
- Managing transitions of care
What is the value of patient care coordination?
Patient care coordination is becoming a standard, particularly within value-based care arrangements, such as Accountable Care Organizations or payor-provider partnerships. Coordinating care can also help address existing challenges, such as:
- Fragmentation of processes between primary and specialist providers
- Poor communication with patients regarding referrals, appointment setting, and next steps
- Missing information between primary and specialty providers, resulting in duplication of services
Effective coordination of care can promote regular patient engagement and education, help automate or improve clinical workflows, and enable greater sharing of data patient health data.
Four ways coordination of care can improve outcomes
Coordinating care supports patient health by focusing on four core components.
1. Support a holistic view of a patient’s health needs
Care coordination is based on relevant and timely information about a patient’s conditions, health goals, and current interventions or care plan activities they’re undertaking.
By answering a series of questions and providing their medical history, patients collaborate with their provider or a care manager to create a comprehensive care plan. The patient receives this concise report, which becomes the backbone of their ongoing self- or assisted management of conditions.
2. Streamline access to care services and providers
Once a care plan is established the care team can deliver services and interventions. Care coordination promotes integration and efficiency through streamlining access to specific programs or specialists and helping the patient navigate disparate systems.
One way that care coordination supports patients outside the clinic is through Remote Patient Monitoring.
Patients can automatically transmit real-time clinical metrics through Internet- or wi-fi-enabled devices. Physicians can use this information to help inform targeted interventions or care decisions and care teams can monitor for readings that indicate a possible intervention is required.
3. Enable patient engagement with actionable health information
Patient engagement is a key performance metric for value-based care. Engaged patients are more likely to track their progress and maintain their treatments. This can lead to improved health outcomes, especially for chronic disease management.
Actionable information is vital to care coordination. It invites the patient to actively participate in the care plan. Whether through telemedicine or telephone touchpoints, a patient portal, or mobile apps, access to integrated data among care teams and other physicians, as well as with patients and their families, is key to engagement and proactive management of conditions.
Education, communication, assessments, and assigned care interventions and tasks are all ways the care team can engage each patient and provide ongoing support between in-person interactions.
4. Manage transitions of care with strong communication
Coordination of care aims to facilitate a seamless continuum of support and advocacy. Encompassing transitions among primary, acute, and long-term health services in various settings, care coordination enhances quality outcomes while saving time and money.
Transitional Care Management (TCM), another value-based care program, uses care coordination as a strategy to maintain health gains as patients move from one setting to another. According to the American Journal of Medical Quality, patients decreased their odds of readmission by nearly 87% when they participated in a TCM program.
TCM prioritizes effective communication and follow-up support within the first 30 days of a hospital discharge. The program emphasizes a strict timeline, in which you or a broader care team are expected to inform and connect with patients by specific follow-up dates and coordinate services between providers and specialists.
How can providers deliver a care coordination model?
Providers can work with patients in several ways to support a card coordination model. These include:
- Use integrated software platforms: Apart from a provider’s electronic health record (EHR), specialized care coordination tools are available to more seamlessly adopt this approach. Software can facilitate care plan development, communication and data sharing between providers and care team members, and track and report quality improvements.
- Become a member of an Accountable Care Organization: Providers join Accountable Care Organizations to deliver coordinated, high-quality services aimed at enhancing patient outcomes and controlling costs. These groups play a crucial role in fostering improved communication between primary care physicians and specialists, as well as facilitating connections between patients and social services when needed.
- Adopt a value-based care model: Alternative payment arrangements, such as the Medicare Shared Savings Program or Next Generation ACO Model, promote care coordination practices. Within these models, providers can place greater emphasis on coordinating patient care while receiving more specific direction and expectations on how to carry out certain activities.
- Enroll patients in care management programs: Chronic Care Management (CCM) is a Medicare Part-B program for patients with two or more chronic conditions. Clinical staff engage patients for at least 20 minutes per month to coordinate care activities. Services include a monthly clinical review, telephone check-ins, physician reviews, referrals, prescription refills, chart reviews and scheduling appointments or services. CCM is reimbursable under the Physician Fee Schedule.
- Identify and address social determinants of health (SDOH): Recognizing and addressing SDOH is becoming a standard part of delivering patient-centered care to improve health equity. Providers can use evidence-based SDOH assessments to engage patients on SDOH, collect data, and address barriers to care through community-based interventions of resources.
Studies show care coordination’s effectiveness
Care coordination plays a crucial role in enhancing efficiency. By establishing essential links, continuity, and consistency in healthcare delivery, it fosters collaboration among care teams and patients, which is essential for achieving goals aligned with value-based care.
Studies demonstrate the significant benefits of care coordination:
- A study published in the American Journal of Managed Care showed an 11% decrease in overall healthcare costs associated with a care coordination model used for chronic conditions. This equated to an average annual savings of $1,364 per patient for health plans.
- Lahey Health in Massachusetts used a care coordination approach to achieve a significant reduction in hospital readmissions.
- The Journal of General Internal Medicine published research that shows “that health plans with better beneficiary-reported care coordination achieved higher HEDIS performance scores.”
- Research indicates that care coordination has led to 56.2% of patients achieving D5 goals in diabetes A1C control, marking a 97.2% improvement in outcomes.
- Coordinated care has been shown to decrease patient costs by nearly 50% compared to fragmented care within the healthcare system.
- According to the Agency for Healthcare Research and Quality, care coordination enhances patient commitment to treatment plans and aligns care with patient preferences, promoting safer and more appropriate healthcare utilization.
- Studies demonstrate that care coordination reduces 30-day readmission rates, improving overall patient outcomes and healthcare efficiency.
ThoroughCare helps providers coordinate care
ThoroughCare is a software platform that helps providers collaborate and deliver digital care coordination. We:
- Streamline the creation of patient care plans
- Facilitate patient enrollment in and delivery of care management programs
- 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
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.
