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Care Coordination | Value-Based Care

What is Care Coordination? 4 Important Features You Need To Know

April 6th, 2022 | 7 min. read



Content Team

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Value-based care can enable worthwhile aims, such as improved patient health and reduced care costs, but it has introduced new, overwhelming challenges to medical providers. 

For example, private insurers and Medicare now use alternative payment models, such as the Merit-based Incentive Payment System (MIPS), to promote value-based care. These models tie provider compensation to specific performance metrics in order to drive change. But in these arrangements, providers find that they could miss reimbursement opportunities if they fail to meet or exceed such metrics.

This shift has the healthcare industry in a bind. 

In order to meet specific performance metrics, care delivery must change and efficiency gaps must close. But that’s difficult to do. Organizational limitations, such as overworked clinical staff and a lack of adequate digital tools to streamline processes, stand in the way.  

As a response, medical providers have looked to integrated care coordination as one possible solution. By automating specific clinical tasks, emphasizing patient engagement, and promoting interoperability through technology, care coordination can be a holistic way to answer the challenges of value-based care.  

At ThoroughCare, we’ve assisted nearly 600 clinics and physician practices across the United States as they transition to value-based care and work with alternative payment models. We’ve helped these groups establish value-based care programs, maximize Medicare reimbursements, and reduce staff burnout all through an overall focus on care coordination.

In this article, we’ll provide a clearer picture of what exactly care coordination involves. We’ll also cover four, core features of care coordination that address value-based care, so you have a base understanding of its aims and some of its practical applications for you and your patients. 

What is Care Coordination?

Care coordination can help engage your patients and streamline their care activities. 

It involves organizing your patients’ various needs as they go between multiple providers. The overall goal of care coordination is to enable a more holistic, personalized approach to healthcare while reducing costs and negative outcomes through increased efficiency

4 Important Features Of Care Coordination

Care coordination consists of four core components. They are:

1. A Holistic Understanding of a Particular Patient’s Health Needs

To provide effective care coordination, you’ll need thorough information about your patient’s conditions, health goals, and the interventions or activities they’re undertaking. All coordination efforts will be based on this information. Learning this detail is also an opportunity to tailor your patient’s care experience. 

A patient-centered care plan can help gather all pertinent health information

With it, you or your practice’s broader team can assess a patient’s priorities and then personalize treatment. Patients complete the care plan with their provider or a care manager. They answer a series of questions and provide medical history through a simple assessment. The result is a concise report that helps isolate a patient’s primary concerns or goals. A patient-centered care plan is, ultimately, the backbone of integrated, coordinated care.  

2. Streamlined Access to Care Services and Providers

Once a care plan is established, services should be rendered. These services will vary based on your patient’s needs, but ideally, access to specific programs or specialists should be streamlined. Care coordination should promote integration and efficiency

As healthcare has increasingly gone digital, home health has been brought into focus. Digital solutions make it possible to support a continuum of care outside a practice office or hospital. Home health is now an integral piece of a patient’s journey.

One such home health solution is Remote Patient Monitoring (RPM), a preventive care program that enables remote vital capture through various digital devices. This program can benefit patients’ health by capturing patient data in near real-time. Providers can then analyze this information to help inform targeted interventions or care decisions. 

RPM, or other related preventive care programs, work with and support the core objectives of care coordination. The program can inform a personalized care experience while helping improve efficiency, for both the patient and your practice. Effective integrated, coordinated care can also streamline a patient’s participation in RPM. 

This can be accomplished with a patient-centered care plan, which can help focus specific goals for RPM participation. By simply utilizing a digital software solution that acts as a hub for RPM activity and data tracking, information can be easily exchanged between providers and care teams. 

A comprehensive care coordination software platform can make it possible for your patient to participate in multiple value-based care programs, simultaneously. This can help your practice maximize reimbursements while providing your patients a holistic, personalized care experience.

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3. Concise, Actionable Information to Support Patient Engagement

Patient engagement is a key performance metric for value-based care. Engaged patients are more likely to track their progress and maintain their treatments. And this can lead to improved health outcomes, especially for chronic disease management. 

As a provider, you’re now tasked with making care services more transparent, more useful, and ultimately more valuable for your patients. Communicating clear, useful information is one way to do so. 

Actionable information is important to the concept of integrated care coordination because it invites your patient into the overall process. It ensures you and those you serve are on the same page, building trust. It also promotes efficiency, as it can encourage additional effort from your patient, as well as reduce potential confusion. 

How you deliver this information, whether it’s about clear care interventions and tasks, or medication guidance, is evolving. Some providers utilize mobile patient apps to engage and inform, whereas other practices rely on care managers to conduct direct outreach by phone or through digital chat tools.    

4. Strong Communication to Help Coordinate Care Transitions 

Lastly, care coordination aims to support a continuum of care. This can encompass primary, acute, and long-term health services that occur in various settings, whether a hospital, your office, or the patient’s home. 

No matter where a patient is at in this continuum, care coordination helps ensure quality, efficacy, and efficiency do not suffer but maintain strong consistency. This can support improved outcomes while reducing costs, which are key aims of value-based care. 

Transitional Care Management (TCM), another value-based care program, is a specific way you can apply the concepts that drive and define care coordination to improve patient transitions. 

TCM prioritizes effective communication and follow-up support within the first 30 days of a hospital discharge. The program places emphasis on a strict timeline, in which you or a broader care team are expected to inform and connect with patients by specific follow-up dates, as well as coordinate services between providers and specialists. 

The idea is that you and your patient are being proactive about their transition out of a hospital, keeping it in focus, potentially preventing a need to return. And according to the American Journal of Medical Quality, patients decreased their odds of readmission by nearly 87% when they participated in the program

This is all due to the way TCM is designed, in which strong communication enables effective coordination and engagement. 

Care Coordination Can Simplify Value-Based Care

Value-based care revolves around general quality performance metrics, such as patient engagement, clinical efficiency, and cost reduction. But it presents you and other providers with a challenge, in that you’re asked to do more with less, or you could fail to maximize reimbursement opportunities. 

Care coordination is a way of practice that shows promise in addressing value-based care’s obstacles. It inherently helps speak to and act upon the performance metrics underlying value-based care. 

But how do you actually implement care coordination?

It’s most effective to implement care coordination with actual programs and services that incorporate the four features detailed above. With Chronic Care Management (CCM), a Medicare care management program, it’s possible to improve patient health outcomes and produce recurring revenue for your organization.

Find out how CCM can help your practice make care coordination actionable.

As well, digital software solutions are available to help your practice embrace integrated, coordinated care. At ThoroughCare, we’ve designed our care coordination software for easy clinical use with an intuitive interface that allows you and your team to engage patients through multiple care management and wellness programs.

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