Prioritizing the Patient’s Optimal Outcomes Through Care Coordination

medicine, healthcare and surgery concept - group of doctors or surgeons discussing spine x-ray on tablet pc computer screen at hospital

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BookshelfCare Coordination – A Tremendous Help

I certainly wished someone had given me a handbook on parenting a child with special needs in the days following our son’s accident. Those early days were so foggy, and we had no idea what lay ahead of us. We simply took one step at a time, at the guidance of our son’s neurologist. With the infant brain being as supple as it is, he answered a lot of our questions regarding our son’s prognosis with, “Only time will tell.” The sole focus for the first three years of our son’s life was to control the seizures and stimulate his brain so that it could heal and develop as best as possible. After his third birthday, the seizures were under control and our son’s neurologist referred us to a neurodevelopmental disabilities specialist. We began seeing her every three months and still do to this day. At our first appointment, she ever-so-gently diagnosed our son with Cerebral Palsy and explained to us the big picture goal is to now help him access the world as independently as possible. Since that initial appointment, she has referred us to several different specialists who now make up our son’s healthcare team and work together to ensure our son is living his best possible life. While my husband and I were never granted a set-by-step handbook on how to care for our son, we were introduced to the model of coordinated healthcare and it was a tremendous help!

medicine, healthcare and surgery concept - group of doctors or surgeons discussing spine x-ray on tablet pc computer screen at hospitalCare Coordination Defined

According to the Agency for Healthcare Research and Quality, “Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system. Clinical coordination involves determining where to send the patient next (e.g., sequencing among specialists), what information about the patient is necessary to transfer among health care entities, and how accountability and responsibility is managed among all health care professionals (doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination addresses potential gaps in meeting patients’ interrelated medical, social, developmental, behavioral, educational, informal support system, and financial needs in order to achieve optimal health, wellness, or end-of-life outcomes, according to patient preferences.” (1) This definition perfectly articulates the type of healthcare my husband and I so desperately needed for our son at the time of his accident and what we are so grateful to have found in our region.

doctor talking to patientThe Quarterback

Over the last four years, our son’s neurodevelopmental disabilities physician has become what Conifer Health Solutions describes in their article, “Improving Patient Outcomes Through Care Coordination and Population Health Management.” The article states, “Patients benefit from having a single point of contact – such as a care manager or personal health nurse – to coordinate care across the boundaries of acute, primary, specialty, post-acute, long-term care, home care and clinic care. Someone who knows their story, their goals, and the barriers and idiosyncrasies that can keep them from achieving those goals. They want someone they can trust to help guide them on the path to improved or stable health. The care manager can be the cog on the wheel that each spoke ties back to – the quarterback or coach of the greater care team that goes beyond the four walls.” (2) We have built a relationship with her and fully trust that she genuinely prioritizes the best health outcome for our son, as well as the most financially efficient route to get there. At one point in time, she demonstrated her loyalty to our son’s optimal care when, despite the risk, she referred us to a surgeon outside of her particular healthcare facility.

family walkingHappy Patients

My husband and I are extremely grateful for our son’s first pediatric neurologist who knew exactly when to refer us to another physician and humbly passed the torch. He is still currently a vital part of our son’s healthcare team. We are also grateful for our son’s neurological disabilities physician who currently treats our son holistically and manages the team of specialists, nurses, therapists, nutritionists, and other healthcare professionals who collaboratively work to provide our son with the best quality of life possible. I’ll leave you with a quote from Medvision’s article on care coordination, “A study by Bain & Company shows that a profit increase of 25 to 95 percent is possible when you increase your customer retention rate by 5 percent. So if you want to increase retention rate, a good place to start is by keeping patients happy with your services. And great care coordination is conducive to patient satisfaction.” (3)

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Thank you!

Jerry L. Stone
MedicalGPS, LLC



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