Delivering Successful Care Coordination: Creating the IT Foundation for Accountable Care (Part Three)

In part three of a five-part series on creating the IT foundation for accountable care, Joseph M. Taylor, vice president and ACO practice leader at the Wayne, Pa.-based FluidEdge Consulting firm, addresses the topic of “The expanded collaboration role between different members of the broader care team.” Parts one and two addressed the topics of “The key elements needed to identify and stratify patient populations,” and “The office and patient workflow, including integrating the role of care coordinators.”

Joseph M. Taylor

The expanded collaboration role between different members of the broader care team

The success of accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) will depend upon physicians who embrace the concept of managing care across the care continuum and leading teams of professionals committed to evidence-based medicine while delivering on continuous quality improvement.

Today, much of the “coordination” conversation is around who is or who should be the “quarterback” on behalf of the patient / member.  Is it “Friendly Insurance Company’s” Case Manager, Condition Management Nurse, Inpatient Review Nurse, and/or Discharge Planning Nurse?  It is the PCP, their Care Coordinator, one of several specialists the patient is using or one of their nurses?  Keeping with the football motif, one thing is for sure, the patient feels like the football.  They are handed off, thrown downfield, punted and sometimes fumbled.   

The Stanford University-UCSF Evidence-Based Practice Center defines care coordination as "the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care."¹   

In the ACO and Personal Physician driven, nurse executed, Care Coordination world, the above definition is so important and truly underscores the role of the Care Coordinator who needs to be:

In short, they need to leverage their role as “trusted source” to help facilitate delivery of “the right care, at the right time, at the right place and for the right cost” – a promise I heard over 25 years ago when I started in this industry.  As I look back, and perhaps age myself, this seems like rural healthcare or Dr. Marcus Welby reborn.  Except this time it is enabled by technology, supported by a Care Coordinator, contains aligned financial incentives, and is focused on the total quality of care provided and improving measurable outcomes. 

Clearly, for patients with multiple conditions and providers, each member of the team tends to have specific, limited interactions with their patient.  In addition, depending on the team member's area of expertise, they also have a somewhat different view of the patient causing the health care team's view of the patient to become fragmented into disconnected facts and clusters of symptoms.  To be pragmatic, there are several obstacles that need to be overcome in this coordinated world.  Just to name a few:

• Appropriate patient selection for Care Coordination is essential as Care Coordination is expensive and resource intensive
• Information exchange among care team participants can be difficult and time consuming, especially beyond the walls of the PCMH/ACO,
• If your patient goes to a competing hospital / ACO care provider, care coordination and integration can get even more complex
• The tools to empower the Care Coordinator, their activities, population / campaign management, that can demonstrate their effectiveness are emerging and the IT vendors’ products are still “maturing”
• Commercial payers each have their own contract, performance measures, program goals, workflow, and different integration points.  They continue to conduct a different part of the care management program for their members who are part of an ACO and require significant data back for their reporting needs
• Many of the Medicare’s ACO program goals and measures are not the same as the commercial payers ACO goals and measures, and
• Most current payer plan designs for ACO and PCMH patients do not directly support and incent positive lifestyle changes, reduction of risky behavior, and/or improved medication compliance in terms of either monthly contributions and/or deductibles/co-pays.

Solving for these obstacles takes a special role, a special person; it takes someone who is very creative, independent and caring.  They need to have strong critical thinking and communication skills, and the ability to work assertively, yet collaboratively, with the diverse group of care team members.  They need to have the tools, skills and desire to:

• Proactively track and support patients as they go to and from specialty care, the hospital, and the emergency room
• Follow-up with patients immediately after an emergency room visit
• Help manage a patient upon hospital admission, including discharge planning, post discharge     follow up and assisting in medication reconciliation
• Communicate test results and their meaning to patients and their families - as needed
• Provide care management services for high risk patients including care plan development and education services for both patients and their family members

The role of Care Coordinator can be very challenging, however; it is also very rewarding, especially if one wants to become directly involved with patients and make a difference in their lives.

Part four of this five-part series will address the topic, “Tools to empower the care coordinator and track patient progress between visits.”