I’ve been in and around healthcare for three plus decades and a concept that has always been front of mind for me is care coordination. This is something that is so important for a patient’s well-being in terms of improved outcomes and satisfaction. It is also a real opportunity for cost improvement. Unfortunately, I’ve seen this concept advanced via discussion but rarely via systemic adoption among providers. In fact, COVID set care coordination advances backward in many ways.
Care coordination is a patient focused process that seeks to single-point, map patient desired outcomes with patient needs. It seeks to connect providers to a common focus and to reduce steps, eliminate redundancy, and restrict unnecessary services or interventions. It in theory, reverses the driver’s seat role among the patient and providers, giving the patient voice the primary role as opposed to the provider (physician, etc.).
The challenge within the U.S. system is regulation and bureaucracy stifle care coordination. While we see regulations in the post-acute arenas prompting certain levels of care coordination, the regulations further segment rather than advance creativity. At the hospital/acute arena, the driver of care tends to be procedural and payment. There simply is little room for a holistic approach and/or a team approach. The driver of the admission is often, the need for an intervention. Multiple providers are involved (physicians) and the primary care provider of the patient by origin, is rarely if at all, involved. If the patient is elderly (the most common hospitalized patient), issues of multiple comorbidities and prior and current treatments confound the hospital stay. Tests are often repeated as no contemporaneous record follows the patient and history, may be sketchy at best. The ability to deliver effective care and coordinate the next step of the journey is bollixed by the need to complete the stay in the shortest time possible.
As more care and procedures for patients sub-65 with little prior comorbidity or controlled comorbidities are pushed outpatient, the inpatient hospital stays are dominated by elderly and/or complex care arising out of the need for major surgeries or trauma. For a senior patient, care coordination can be the difference between poorer outcomes, lengthier stays, and the need for additional inpatient stays, post-acute.
According to the Agency for Healthcare Research and Quality, care coordination is: “Care coordination in the primary care practice that 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. The main goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care”.
Broadly, care coordination involves a specific framework that emphasizes data sharing, teamwork, and patient-focused assessments clinical and psycho-social in nature. The desired outcome is a shared plan of care that covers admission, in-stay communication and education, and transitions from acute to post-acute. In some cases, the stay maybe an inpatient post-acute stay (e.g., SNF) with the same series of events (shared plan of care, communication and education, transition planning).
COVID in particular, illustrated how fractured the health care system in the U.S. remains. Care denials and delays became the norm and patients lost connections with their physician, clinics, and other providers. Access, already a problem, caved in many cases and for some, remains a continued problem as staffing shortages already at-risk, manifested. A few weeks ago, I wrote a post about access problems for SNFs and Home Health resulting post COVID. The post is here: https://wp.me/ptUlY-vL
The U.S. healthcare system is notorious for its silos. The silo issue is what care coordination attempts to ameliorate. For a senior adult patient, this issue of silos is incredibly perilous. Without direct connection within the system, it is not uncommon for a senior to either avoid care due to the access complexity or receive care that is unnecessary or unwanted, driven entirely by systematized processes. In other words, I have seen older adults all too often, become victims of polypharmacy for example, simply by seeing multiple physicians, all of which prescribe without going through medication reconciliation BEFORE writing the script. I’ve seen repeat procedures within the same day – multiple tests that don’t get checked because the patient follows orders and doesn’t ask questions. I’ve seen X-rays taken two days prior lead to an MRI, just to be cautious.
Objectively, and I have written this before, the system needs to be redesigned to advance the goals of patient care as primary, in fact, driven by a fundamentally simple concept known as primary care. The need for a different system and one that emphasizes care coordination, is succinctly stated by the Institute of Medicine.
- Current health care systems are often disjointed, and processes vary among and between primary care sites and specialty sites.
- Patients are often unclear about why they are being referred from primary care to a specialist, how to make appointments, and what to do after seeing a specialist.
- Specialists do not consistently receive clear reasons for the referral or adequate information on tests that have already been done. Primary care physicians do not often receive information about what happened in a referral visit.
- Referral staff deal with many different processes and lost information, which means that care is less efficient.
For readers interest in care coordination and applications, tools, and additional reading, I’ve provided some resources below including a presentation I did with some colleagues at a LeadingAge national conference a few years back.
https://www.qualityforum.org/ProjectDescription.aspx?projectID=73700
https://www.ahrq.gov/ncepcr/care/coordination.html