Today’s healthcare system is complicated, fragmented, and often difficult to navigate. Patients must interact with multiple providers across many specialties, under various organizations with differing processes. According to the Department of Health and Human Services, the average Medicare beneficiary sees at least two primary care providers and five specialists, while those with multiple chronic conditions may see up to 16 physicians per year. (1)
It is easy to understand why patients become confused and even frustrated about being referred to multiple specialists. How to make appointments and what to do afterward can be confusing just by itself. Often, specialists have limited patient information and may be missing test results that were previously performed, or, lack a medical history on the patient being referred. Following the referral visit, in the event the primary care provider fails to receive a follow-up from the specialist, the situation only worsens. The different processes and missing information can add up to care that is uncoordinated, inefficient and incomplete.
What is Care Coordination?
Care coordination is an essential part of delivering comprehensive, safe, and effective care. It involves intentionally organizing patient care activities and sharing information across all providers involved in a patient's care. Care coordination is identified by the Institute of Medicine as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the US healthcare system. The implementation and delivery of well-designed, targeted care coordination can improve outcomes for patients, providers, and payers. (2)
Why Is Care Coordination Important?
When healthcare providers effectively coordinate patient care, outcomes improve and medication errors decline. Improving care coordination reduces unnecessary and repetitive testing, decreases unnecessary emergency room visits, and prevents hospital admissions which lead to better quality care, improved outcomes, and lower costs. (2)
How is Care Coordination Measured?
There are various methods for measuring coordinated care including patient surveys such as CG CAHPS. A few of the questions included in this survey that pertains specifically to care coordination include:
- The Healthcare Provider had your medical records during your visits?
- The Provider’s office followed up with you to provide results of the text or x-ray?
- Did you need help from your care team to manage care, tests, or treatment from a different provider?
- Did you receive help from your care team to manage care, tests, or treatment from different providers?
How Can Care Coordination be Improved?
The necessity for care coordination is apparent, however, there are many obstacles within the current system that must be overcome in order provide this level of care. Medical practices can take a coordinated care approach by implementing a few of the following care coordination activities:
- Establishing accountability and agreeing on responsibility.
- Communicating and sharing information.
- Helping with transitions of care.
- Assessing patient needs and goals.
- Creating a proactive care plan and sharing the plan with the patient.
- Monitoring and responding to the changing needs of patients, including follow-up.
- Supporting patients' self-management goals.
- Working with community resources.
- Aligning resources with patient and population needs.