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:
Specific activities can include:
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:
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.
Coordinating care supports patient health by focusing on four core components.
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.
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.
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.
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.
Providers can work with patients in several ways to support a card coordination model. These include:
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:
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 activities fundamental to value-based care, including:
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 objective
ThoroughCare is a software platform that helps providers collaborate and deliver digital care coordination. We:
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.