Preparing for Care Coordination

Care coordination was identified by the Institute of Medicine as a key strategy for improving the effectiveness, safety, and efficiency of the healthcare system. Targeted care coordination activities, when they get to the right people, can really improve outcomes for not just patients but also providers and payers.

This blog and its predecessor newsletter, has described the evolution of hospital case management over the years.  How we've gone from the original clinical model, to the functional model and to the era of outcomes achievement. With the rapidly evolving entry into a value based environment, it should come as no surprise that once again, hospital case management programs are changing too. But it hasn't been easy.

Unfortunately, many hospitals are still mired down with the discharge planning/utilization review  tasks of 2nd generation models. Regular readers know that 2nd generation models, aka as functional models, came about after the management engineers of the 1990s sprinkled fairy dust over the heads of social workers and utilization review nurses and created pseudo-case management departments charged with discharge planning and utilzation review activities.  In many hospitals, nurses were no longer held responsible for initiating their patients' discharge plan; instead a small cadre of case management FTEs became the discharge planners, the discharge plan logisticians, and the utilization reviewers - a burdensome array of responsibilities none of which were done optimally.  As a result, discharge preparations were minimal, readmissions escalated, medical necessity requirements were perfunctorially applied, and denials increased.

But as 4th generation models of care coordination across the continuum are popping up, there is universal recognition that there are unique populations of acute care patients who need special attention; not only to help them navigate through the acute episode of care, but across the entire continuum. As ACOs proliferate along with new payment and delivery of care models, many hospital execs and case management program leaders have been successfully preparing for the new marketplace.   Predictive analytics or their surrogates are being used to identifty high risk, high cost patients who would benefit most from care coordination;  'systemness' stragegies are being shaped across integrated delivery systems; networks of preferred post acute providers are being formed; practice profiles are being distributed to  the medical staff;  centralized post acute resource centers are being created to off-load the logistics of post acute service arrangements from the care managers and the nursing staff; and selected patients are being monitored closely and, to the extent feasible given the size of an organization, seamlessly.

As we visit hospitals across the country, we're finding out that in the rush to address the coordination opportunities, some of the early silo initiatives are having unintended consequences. In a New York Times article by Paula Span entitled “The Tangle of Coordinated Health Care”, she highlights how hospitals, accountable care organizations, Medicaid programs, home care agencies, senior centers and other community organizations have all established their own care coordinators. Multiple care coordinators from different care settings are making home visits and recommending activities already ordered by another coordinator. Most coordinators are not aware that others have visited until they talk to the patient. What patients need, rather, is access to fewer coordinators who can work together across diverse care settings to help them manage their care plans. 

It is clear that care coordination without care plan continuity is detrimental to patient care and may compromise desired outcomes. When considering how care coordination will work at your facility, ensure that it starts with an enterprise-wide vision that can provide seamless continuity of access and information across multiple care settings.   What patients need, is access to a coordinator who is fully empowered with the right tools, enabling him or her to work across diverse care settings to help patients access and manage their care.