Care coordination includes organizing patient activities and services across multiple providers. The approach prioritizes communicating all relevant information to the participants involved in the person’s care. Its overall objective is to fulfill an individual’s care needs and preferences through high-quality, personalized engagement.
What is the value of patient care coordination?
Patient care coordination is becoming a standard, particularly within value-based care arrangements, such as Accountable Care Organizations or payor-provider partnerships. Coordinating care can also help address existing challenges, such as:
- Process fragmentation between primary and specialty providers
- Poor communication with patients regarding referrals, appointment setting, and next steps
- Missing information between primary and specialty providers, resulting in duplication of services
It is possible to increase the sharing of patient health data, automate or improve clinical workflows, and encourage regular patient engagement and education through effective care coordination.
Pillars of Seamless Care
Continuity of Care
Electronic health records (EHRs) play a crucial role in ensuring continuity of care by providing a centralized repository for patient data that is accessible to all authorized healthcare providers. This allows for more informed and collaborative patient treatment.
The need for smooth transitions between different healthcare settings, such as hospitals, clinics, and home care, is also emphasized by seamless care. During these transitions, effective communication and coordination are crucial for eliminating gaps in care and ensuring that patients receive consistent care.
Care Coordination
Collaboration among varied healthcare experts, such as primary care physicians, nurses, chemists, and other medical professionals, is encouraged by seamless care. Interdisciplinary teams collaborate to create comprehensive treatment plans that address a patient’s physical, emotional, and social well-being.
To improve care coordination, advanced communication technologies such as encrypted messaging systems and telehealth platforms are essential. These solutions provide real-time information interchange, allowing healthcare providers to stay connected and up to date on the state of their patients.
Patient Engagement and Empowerment
The necessity of incorporating patients into their healthcare decisions is recognized by seamless care. Shared decision-making, in which healthcare providers and patients work together to make informed decisions, boosts patient participation and develops a sense of ownership in their care.
Patients must be well-informed about their health issues, treatment alternatives, and self-management strategies to receive seamless care. Health literacy efforts and patient education programs help to enable people to actively participate in their care.
Four ways coordination of care can improve outcomes
1. Support a holistic view of a patient’s health needs
Care coordination is based on relevant and timely information about a patient’s conditions, health goals, and current interventions or care plan activities they’re undertaking.
By answering a series of questions and providing their medical history, patients collaborate with their provider or a care manager to create a comprehensive care plan. The patient receives this concise report, which becomes the backbone of their ongoing self- or assisted management of conditions.
2. Streamline access to care services and providers
Once a care plan is established the care team can deliver services and interventions. Care coordination promotes integration and efficiency through streamlining access to specific programs or specialists and helping the patient navigate disparate systems.
One way that care coordination supports patients outside the clinic is through Remote Patient Monitoring.
Patients can automatically transmit real-time clinical metrics through Internet- or wi-fi-enabled devices. This information can be used by doctors to help make targeted interventions or care decisions, and care teams can keep an eye out for readings that might mean an intervention is needed.
3. Enable patient engagement with actionable health information
Patient engagement is a key performance metric for value-based care. Engaged patients are more likely to track their progress and maintain their treatments. This can lead to improved health outcomes, especially for chronic disease management.
Actionable information is vital to care coordination. It invites the patient to actively participate in the care plan. Whether through telemedicine or telephone touchpoints, a patient portal, or mobile apps, access to integrated data among care teams and other physicians, as well as with patients and their families, is key to engagement and proactive management of conditions.
Education, communication, assessments, and assigned care interventions and tasks are all ways the care team can engage each patient and provide ongoing support between in-person interactions.
4. Manage transitions of care with strong communication
Coordination of care aims to facilitate a seamless continuum of support and advocacy. Encompassing transitions among primary, acute, and long-term health services in various settings, care coordination enhances quality outcomes while saving time and money.
Another value-based care program, Transitional Care Management (TCM), uses care coordination to keep patients’ health gains as they move from one setting to another. According to the American Journal of Medical Quality, patients decreased their odds of readmission by nearly 87% when they participated in a TCM program.
TCM prioritizes effective communication and follow-up support within the first 30 days of a hospital discharge. The program places an emphasis on a strict timeline, requiring you or a broader care team to inform and communicate with patients by specific follow-up dates, as well as coordinate services between specialists and providers.