Care Coordination Guide

Want to know how care coordination benefits your medical business, increases doctors’ reimbursements and improves patient health? Read this comprehensive guide.

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What exactly is 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.

Why is care coordination needed

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.

Healthcare interoperability is broken

You know that a patient’s health is affected by factors outside the 4 walls of the physician’s office.

Unfortunately, our current healthcare system is disjointed, and interoperability is a challenge.

A patient sees their primary care physician and several specialists over the course of their life.

Both the PCPs and specialists often operate in the fee for service world.

Neither party has the right incentives nor the bandwidth to help the patient navigate their own care.

It gets worse when when the patient needs assistance from social or community resources. 

PCPs lack bandwidth and incentive

More often than not, in the fee for service world, the provider doesn’t have the time to truly explain why the patient needs to see certain specialists, why they need to go for their preventive appointments, why they need to get labs and tests done etc.

Primary care physicians don’t always get the consult notes back from specialists that would complete the referral loop, therefore enriching the patient record and allowing them to deliver better, more informed care during the next patient visit.

Specialists lack complete patient information

Specialists almost never get the appropriate information needed to deliver immediate, tangible care to the patient referred to them, have to redo tests that might already have been done, are backed up with referrals that are not always needed (and could have been avoided with e-consults). 

Patient care continuum

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.

  1. Transition between care team/individuals – eg when patient care is moving between various specialists, PCP and / or inpatient vs outpatient settings
  2. 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.

Continuity of care and care coordination 

Arguably, continuity of care intermingles with care coordination.

Is continuity of care the same as care coordination? 

There’s no right or wrong answer.

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.

Need help from our care coordination team? Reach out.

    Examples of care coordination

    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.

    Care coordination in fee for service world 

    Right off the bat, it might seem that care coordination is not meant for practices dwelling in the world of fee for service.

    Take a deeper look, instead.

    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).

    What does that amount to in a fee for service world?

    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. 

    The notion that preventive care reduces fee for service revenues is simply a fallacy.

    Care Coordination in Value-Based Healthcare

    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.

    How to put Care Coordination in action

    Start with a simple approach. 

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

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

    Need help from our care coordination team? Reach out.

      Different parts of care coordination 

      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

      Disease Management and care coordination

      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:

      1. Supports the physician+patient relationship
      2. Supports patient’s plan of care 
      3. Utilizes evidence based clinical guidelines
      4. Supports prevention of complications 
      5. Provides tools for improving overall health
      6. Provides tools and pathways for patient reported outcomes
      7. 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”

      Case Management and care coordination

      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”.

      Use a care coordination software

      I recommend using a care coordination software because:

      1. It includes a patient registry
      2. You automate patient outreach
      3. 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:

      1. Send text messages automatically as part of a predetermined campaign 
      2. Allow you to create various templates of messaging so you can experiment with and determine what messaging works and what doesn’t 
      3. 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. 
      4. 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.
      5. 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.
      6. 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.

      Need help from our care coordination team? Reach out.