Care Coordination is not a synonym for discharge planning
by Stefani Daniels, Founder and Managing Partner
Published on Jun 07, 2019
Review the literature and you'll find over 40 definitions of care coordination. In 2007, the AHRQ in its landmark paper Closing the Quality Gap, described it as a "deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of healthcare services." Subsequent publications have been pretty consistent in noting that care coordination activities should be reserved for targeted populations of high risk or pre-high risk patients in the community and in the hospital.
However, when you dig into articles written by and about hospital case management, you will find that many authors seem focused on using 'care coordination' as a metaphor for coordinating the discharge plan from the hospital to the community and how a well coordinated discharge plan can reduce emergency department visits and readmissions. But if you refer to definitions and descriptions of care coordination published by the AHRQ, the Institute of Medicine, the National Health Policy Forum, the US Department of Veteran Affairs and dozens more, the intent of care coordination is the facilitation of the most appropriate care, in the right order, at the right time, and in the right setting. In my mind, that conjures up a lot more than coordinating a discharge plan.
The targeted populations mentioned in the majority of research articles are those with complex medical needs and related underlying factors that impact their health - social, environmental, financial and cultural. These vulnerable patients would undoubtedly benefit from targeted care coordination beginning at the time of hospital admission and extending through community-based transitional care. Many of the more recent studies demonstrate the success of care coordination models that span the continuum such as The Johns Hopkins Community Health Partnership (J-CHiP) initiative. Their model starts with hospital case managers in two of their East Baltimore hospitals and extends into the community for those patients discharged to local skilled nursing facilities as well as several ambulatory primary care sites.
Nationally, hospital execs and their ACO and care coordination colleagues are working behind the scenes to identify community partners and stakeholders that can assist in improving care coordination across the continuum. Then, using claims data, clinical data elements from the EHRs, utilization data, and/or reports from payers, they risk-stratify entire populations to identify problems, implement evidence based interventions and address the gaps in care that result in readmissions and avoidable visits to the ED.
While managing the safe transition from one level of acute care to another and from acute care to the community is a 'given' for most hospital case managers, care coordination is the idea that all the hospitalists, consulting specialists, nurses and care team members are communicating and sharing information to ensure that everyone is acting as a team to meet the patient's needs. It's about working together rather than working as separate entities. Unfortunately, this is far from what most patients experience. Breakdowns are everywhere and they are not exclusive to patients with complex health needs....they happen to all of us.
So, it isn’t surprising that when The Commonwealth Fund ranked the healthcare systems of 11 industrialized countries, the U.S. was not ranked highly for its ability to provide coordinated care. In fact, in comparison to the other countries studied, the U.S. placed last in efficiency—largely due to lack of communication among healthcare providers.
At its core, care coordination is just what the name implies: A mechanism through which teams of health care professionals work together to ensure that their patients’ health needs are being met and that the case manager is pro-actively advocating for the right care and at the right time. Care coordination activities are numerous and varies from organization to organization. But at its heart it means having a single consistent resource to mobilize multiple participants who individually provide specialized knowledge, skills, and services, and who together potentially provide a comprehensive, coherent, and continuous response to a patient's unique care needs.
In my view, a robust care coordination program targeted on the most needy inpatient population pays off financially and in terms of customer satisfaction. But it requires the persistent support and encouragement of the executive team and medical leadership to re-engineer the culture and successfuly overcome the tensions and paradoxes of new expectations.
Is it worth it? Of course it is. Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient's care. Nevertheless, patients with serious illnesses or chronic conditions, who account for a disproportionate share of hospital costs, tell stories about the gaps that often occur in communication between patients and care team members, as well as between specialists. These communication gaps can hinder the multidisciplinary group from working toward common patient-centered goals in a coordinated “interdisciplinary” manner.
Over the years, I've told client hospitals that care coordination is too expensive to provide to all inpatients and isn't needed by most. I stand by that advice knowing that according to MedPac around .3 to 25% of inpatients are outliers - those patients whose costs or days in the hospital exceed the expectations due to the complexity of their medical conditions or their challenging post acute needs. Those are the hospital's most vulnerable patients and in a marketplace punctuated by value based payment systems, they are the ones who warrant oversight by the hospital case manager to help them and their families through the journey to recovery. As Chen wrote back in 2000, “Case management implicitly enhances care coordination through the designation of a case manager whose specific responsibility is to oversee and coordinate care delivery [targeted to] high-risk patients [with] diverse combinations of health, functional, and social problems.” The same holds true for 2019.