In discussions of care coordination, one may hear it described as the process of guiding patients across care settings or managing the care of patients with chronic diseases or trying to help patients reduce unnecessary readmissions. Actually, it’s all of these things and more.
Defining Care Coordination
The Agency for Healthcare Research and Quality (AHRQ), after consulting many sources, came up with this definition:
“Care coordination is 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 health care 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.”
“Deliberate organization of patient care” or, in simpler terms planned care … whatever its specific application, coordinated care is planned care. And “planned” means something that goes beyond a doctor’s orders or treatment plan. Planned care requires an entire care team comprised of multiple providers and team members dedicated to the delivery of quality health care to their patient population.
Components of Care Coordination
The components of care coordination, according to AHRQ, include:
- Essential care tasks and responsibilities
- Assessment of a patient’s care coordination needs
- Development of a coordinated care plan
- Identification of team members responsible for coordination
- Information exchange across care interfaces
- Interventions that support care coordination
- Monitoring and adjustment of care
- Evaluation of outcomes, including identification of care coordination issues
Coordinating All Aspects of Patient Care
As healthcare organizations form ACOs and medical homes, they will be required to effectively coordinate all aspects of care across populations and care settings.
A March 2011 Commonwealth Fund consensus report on combining these approaches to health care reform observes that care coordination will be the linchpin of this transformation:
“The effective coordination of a patient’s health care services is a key component of high-quality, efficient care. It provides value to patients, professionals and the health care system by improving the quality, appropriateness, timeliness and efficiency of decision-making and care activities, thereby affecting the experience, quality and cost of health care.”
The Role of Health IT
The consensus report also emphasizes the role of health IT in care coordination, while asserting that much of today’s existing information technology is inadequate to the purpose:
“Anchoring the electronic health record (EHR) in the traditional visit-based care delivery model limits the potential of the medical home to generate paradigm-shifting care delivery transformation and the positive outcomes it promises. Health IT requires new functional capabilities, such as multiple team member access and permissions, care management workflow support, integrated personal health records, registry functionalities, clinical decision support, measurement of quality and efficiency, and robust reporting.”
The bulk of the technologies required to achieve these goals are already available. Among the reasons they’re not being properly deployed in most cases are these:
- Electronic health records are often not designed to fully support population health management initiatives or care coordination workflows.
- Registries tend to be focused on patients with particular conditions, rather than entire populations.
- Care management workflow support is still a relatively new concept and not widespread, but one that more and more groups are embracing.
- Some provider organizations lack the infrastructure to consume new technologies and transition to new processes.
Conclusion
Technology tools are being used to improve communications across care settings, especially during transitions of care. These range from traditional point-to-point interfaces to physician and patient web portals to secure electronic messaging. Even computer faxing has its place as the industry moves from paper to electronic documentation of care. The automated stratification of patients into different risk categories is also important to groups seeking to do population health management.
The effective coordination of a patient’s health care services is a key component of high-quality, efficient care. It provides value to patients, professionals and the health care system by improving the quality, appropriateness, timeliness and efficiency of decision-making and care activities, thereby affecting the experience, quality and cost of health care.
Learn More
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