Outsourced Care Coordination

Care coordination is a conscious, deliberate effort to help patients navigate the healthcare and social services ecosystem for better health outcomes.
Care coordination might involve helping patients navigate through primary care and specialist care as and when needed.
It might include medication management and adherence assistance.
It may include navigating social or community services available to a patient.

We all want to achieve safer, more effective care, better health outcomes for our patients. Care coordination brings the biggest impact to closing healthcare care gaps.
Care coordination is needed because:
1. Healthcare interoperability is broken, hence automated care coordination is not possible
2. Primary care doctors lack bandwidth and incentive to execute regimented care coordination
3. Specialists lack complete patient information / a 360 degree view of the patient

Essentially, the entire care of a patient ends up leaning towards disjointed episodic, acute care that breaks during transitions of care.
There are two kinds of transitions to be aware of.
– Transition between care team/individuals – eg when patient care is moving between various specialists, PCP and / or inpatient vs outpatient settings
– Transition between time – eg life stages of an individual, episodes of care, acuteness of the illness.

Those are the primary breakdown points that care coordinators or care managers need to be acutely aware of.

Arguably, continuity of care intermingles with care coordination.
Continuity of care occurs due to deliberate care coordination (in my humble opinion). If continuity of care is defined when physicians, medical records, individuals come together during episodes of care, then care coordination certainly contributes significantly to continuity of care.
Essentially, for continuity of care to be successful, information flow continuity has to occur – be it via CCDA or patient preferences etc. Additionally, relational continuity has to exist as well – between the patient and their clinical care team. Finally, there had to be continuity of a patient’s management of care.
All of the above, in my opinion, can be manifested via care coordination.
If care was better coordinated, information , patient preferences, social determinants of patient’s health were better communicated between the entire care team, it could significantly improve the outcomes for patients, payers and providers.

There are a couple of ways of achieving coordinated care. It can get overwhelming when you’re just getting started.

Creating a proactive care plan, assessing patient needs and goals might even be a part of what your team already does – That’s an example of care coordination.

Some (very few) practices establish staff responsibility and accountability around care plans, transitions of care, sharing health records proactively with care team – another example of care coordination.

Some practices take responsibility of supporting patient’s self management goals or even linking them to community resources – another example of care coordination activities.

Of course, there are broader, more regimented approaches like patient centered medical homes, care management, medication management as well.

The notion that preventive care reduces fee for service revenues is simply a fallacy. Even fee for service providers are held to HEDIS quality measures. Especially for primary care practices, closing care gaps of quality measures requires you and your staff to coordinate care of your patients across specialists, labs etc.

In addition to that, you’re required to see the patient more often for maintaining care levels (tests done in office). This means more tests, more patient visits.. in other words, more chargeable events. More preventive care means closing more care gaps, better scores, higher upcoming reimbursements and possible bonuses. If you do this well, almost 80% of your daily patient volumes could be filled with preventive care, mostly delivered by cheaper resources. 

It’s not hard to understand the value and impact of care coordination for providers that are reimbursed by value based payment models. You get paid for preventive care, and for reducing the total cost of care per patient while improving their health scores.  Value based payments are tied directly to reduced readmission rates, decreased lengths of stays at hospitals, and lessened ICU mortalities. 

The only way to achieve these are to deliver as much preventive care as possible and to allow 24/7 patient access to care coordinators that can triage patient’s care concerns.

For chronic care management, where patients end up costing payers significantly more, preventive care plays an even bigger role in reducing repeat/preventable appointments, lab tests, hospital admissions etc.

Start with a simple approach. 
– Decide which high risk conditions you’re going to manage
– Follow the HEDIS/NCQA clinical guidelines for measurements
– Decide or follow the HEDIS/NCQA clinical guidelines on the care plan for each of those conditions
– Create an intervention plan when patients are non adherent 
– Decide on staff responsibilities, KPIs
– Plan on regularity of staff reporting, meeting
– Create a patient registry from your EMR 
– Stratify your patients based on risk
– Assign patients/ patient panel to staff
– Monitor progress at those agreed upon meetings
– Course correct as needed

If you don’t have the bandwidth to do the above, outsource the functions to a care coordination company

Care coordination means different things to different people, all centered around patient care. If you look at AHRQs definition, they have a very nice pictorial representation of what falls under the purview of care coordination, from various perspectives.

Care coordination ultimately might involve coordination of one or more of the following 
– Primary care
– Specialist care
– Laboratory /tests
– Inpatient care
– Mental health care
– Patient family support
– Community resource support 
– Medication adherence/ pharmacy coordination 
– Long term care
– In home care
– Medical history/CCDA interoperability between care settings

“A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.” ~ Definition by “The Disease Management Association of America“

So, is disease management the same as care coordination? Or is it more like population health management? Disease management does a couple of things:
– Supports the physician+patient relationship
– Supports patient’s plan of care 
– Utilizes evidence based clinical guidelines
– Supports prevention of complications 
– Provides tools for improving overall health
– Provides tools and pathways for patient reported outcomes
– Accentuates the need for patient self education and self management

All of the above are abetted by care coordination. In fact, case management and disease management can be / are considered as parts of “coordinated care models”

“A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes” ~ Defined by “The Case Management Society of America“

Case management is closely related to care coordination. If you assign designated care managers to specific patient populations (ie fixed number of “cases” / patients), this enhanced care coordination even further due to the focus that a case manager can bring to their “cases”.

I recommend using a care coordination software because:
– It includes a patient registry
– You automate patient outreach
– Task management and reminders are automated
– As you can tell this involves a lot of outreach to patients – via text, email, phone calls, voicemails, faxes etc.
– It is nearly impossible to achieve these at scale if you do not use a care coordination software or a medical CRM.
– Automated communications helps alleviate some of these pains.
– Use a healthcare CRM that is tied to your patient registry to guide the care gap outreach campaigns.

However, do not leave the outreach in the hands of technology alone. Even if technology is able to solve 50% of your outreach efforts, that’s 50% less work your staff has to do. 

Your technology choice should allow you to:
– Send text messages automatically as part of a predetermined campaign 
– Allow you to create various templates of messaging so you can experiment with and determine what messaging works and what doesn’t 
– Allow you to have 2 way communications with your patients. – Patients tend to reply back to the text message they receive. They do so whether you monitor that text message inbox or not. 
– Send your campaign message as a voice note for phone numbers that are landline numbers – even better, call patients with a pre recorded campaign message and allow patients to “press one to talk to our care coordinator now”. In other words, it should tie into your phone tree / IVR.
– If you don’t have the staff to answer phone calls, then allow patients to make appointments by themselves 24/7. Most EMRs already have some functionality to allowing patients to book appointments themselves – use that feature.
– Escalate non respondent patients to your care coordinators or someone else that you designate. Don’t wait until the end of the year or month to get “reports”. This doesn’t leave you with much time to actually act on them.

Care coordination generally leads to higher reimbursements each year. It also allows you to deliver higher levels of patient care.  To establish a care coordination program, you would need, at least:

– A robust training program, ready to go patient assessment program, documented workflows , call center software.
– A care team for calling and assessing patients. The care team needs an operational manager and a clinical manager (eg a registered nurse). The care team also needs to call and enroll patients into the program. This has to be documented.  
– Complete, comprehensive care plan for patients with specific pathologies or disease groups. The plan needs to address the established HEDIS measures, include referrals and regular visits (in office or televisit).
– Intervention plan for non adherent patients. Patients tend to drop off the care coordination programs, so the team needs to constantly add patients each week, to balance out the patient churn.
– 20+ minutes / month spent on non face to face / clinical care time. These constitute the care coordination activities.

As a general rule of thumb, you need:
– 1 operational director
– 1 clinical director
– 1 registered nurse / 6-8 care team staff that calls patients
That’s about 8-10 people needed to ensure you can bill for 1000 patients / month. Enrollment is not enough – you need to be billing for those patients as well. 

Most hospitals and practices fail at the enrollment step itself, due to the vastly increased overheads, limited availability of existing overburdened staff.

Once hospitals or healthcare practices address the enrollment challenge, they face the patient churn problem. New patients need to be added to the program on a daily basis because patients keep churning out of the program on a daily basis. Existing patients need to be engaged enough to stop unenrolling from the program.

With labor shortages , staffing , training and retaining staff are a problem.

– Chronic care management
– Annual wellness visits
– Transition care management
– Behavioral health integration

Our outsourced care coordination team can be an extension of your care coordination staff or can handle your care coordination programs end-to-end, remotely.

Initial Steps
– First we sign a business associate agreement (for HIPAA reasons), service agreement (the services we will provide to you), an NDA (non disclosure agreement).
– Next, you assign a primary point of contact from your group/ hospital. We will coordinate, escalate, report to this person. 
– Your staff sends us a list of your MEDICARE patients. You are welcome you send us any patients that you want under your care coordination program. 
– Your staff grants us remote access to your EMR. We will be logging all our activities in your EMR so you don’t have to hunt down data.
– Our outsourced, remote care coordination team starts the process. We handle everything from this point onwards , in tight coordination with your staff.

Most (at least Nisos Technologies) care coordination teams help with the following:
– We acquire a phone number, register the caller ID on your behalf. We do the same with a fax number as well. We handle all incoming and outgoing communications related to your outsourced care coordination program using these numbers. You have full access to all communications sent or received by us at any time. Simply log into our care coordination software, and you will get access to everything we do. This phone number will always belong to your healthcare system.
– We use our care coordination software to stratify all the patient information you sent us. We will then confirm patient eligibility. This allows us to build out patient cohorts for specific care management programs / pathways and recommend the same to you.
– We will confirm the clinical pathway, care templates, encounter notes that we will use during our engagement with you. Your assigned point of contact will receive a copy of everything at this step.
– We make sure that patients get their welcome letters. When we reach out to patients, we confirm their preferred mode of communications and send out welcome letters according to patient preferences.
– We upload each patient’s consent into your EMR in addition to uploading it to patient records in our care coordination software. This, as you know, is required to meet compliance standards.
We make sure that we create patient care teams that include the clinical staff,  specialists, pharmacies, relatives etc. We establish a relationship with the entire care team.
– We start calling patients, completing their intake assessments, documenting assessments and patient health goals – all in your EMR.
– We consult the cohort clinical plans and start making required appointments for each patient. This could include in office appointments, televisit appointments, specialist appointments, laboratory and diagnostics center appointments, pharmacy prescriptions etc
– We remind the patients and follow up with them to ensure that they keep their appointments. This is similar to what our medical call center and medical answering services teams do.  
– We make sure to close the loop for each such appointment by obtaining the consult / encounter notes from the appropriate provider office. Pharmacy measures sure usually closed by pharmacy claims. We ensure that the patient has picked up the prescribed medications by connecting with the patients and reminding them to pick up their medications. On top of this, our medication adherence program can also help with increasing patient medication adherence.
– Each month, we review and update patient’s health goals by talking to each patient. 
– In case of non adherence from certain patients, we follow the intervention plans as agreed upon at the beginning of our engagement. Of course, we escalate all non adherence information to your healthcare system as well.
– From a reporting and documentation point of view, we make sure that all care plans are uploaded to your EMR to ensure that we’re all on the same page. Each time we are able to connect with a patient, we make sure that the encounter summary notes are added to your EMR as well. We will share risk reports with your designated point of contact on a regular basis.
– Finally, our outsourced medical billing team can also handle the monthly billing on your behalf.

Following are the key performance indicators (KPIs) that many of our customers ask for. We happily comply with these industry standard KPIs. Of course, we can simplify these further by monitoring
– Patient satisfaction score
– Eligible patients vs enrolled %
– Enrolled patients vs billed %
– Urgent Care / Hospital (re)admission rates

No. Members stay enrolled in managed care plans and continue
to see the same doctors. They do not pay anything extra – in fact, they get an extra layer of support with a care team that handles their care. Patients are assigned a care team – including a care coordinator. This team coordinates their physical and behavioral health care appointments, in addition to connecting them with community services and housing, as needed by each program's requirements.

There are specific eligibility requirements that might require patients / members to have at least two of the following chronic conditions / illnesses:
– chronic obstructive pulmonary disease
– diabetes,
– traumatic brain injury
– chronic or congestive heart failure
– coronary artery disease
– chronic liver disease
– chronic kidney disease
– dementia or substance use disorders

Other eligible patients might include members with Hypertension (high blood pressure) and one of the following:

– chronic obstructive pulmonary disease
– diabetes
– coronary artery disease
– chronic or congestive heart failure

You can also enroll patients with one of the following:
– major depression disorders
– bipolar disorder
– psychotic disorders (including schizophrenia)
– Asthma

Well designed care coordination teams help patients and members with:
– managing self care
– care coordination between various health related services that a member needs
– Promoting health and a healthier lifestyle
– Rigorous, comprehensive transitions of care (where care coordination fails regularly). This could include helping with admissions and discharges, reducing avoidable hospital admissions and readmissions
– Strengthen the support from family and support network for patients
– Referral coordination for various necessary medical, social and transportation services. This could include proactively sharing health status, CCDA, medical conditions, medications and other relevant information with all involved parties.

This really varies on the acuity of the member / population under management of each care coordinator. Some cases might require weekly, biweekly or monthly touch points. While, other severe cases may require daily touch points.

To some extent, you can. It would depend on the patients' / members' comfort level and adherence to automated activities. In our experience, in medically underserved areas, automated care coordination is not very fruitful.