Care Coordination Key Component of Triple Aim Success
Healthcare providers have increasingly implemented programs aimed at coordinating patient care across a fragmented healthcare continuum. Although these programs vary widely in structure and style, the primary goals of care coordination programs—to improve disease outcomes while containing overall healthcare costs—tend to be consistent across organizations.1
Active Coordination Equals Improved Outcomes
The positive impact of Care Coordination is well documented. In a study published in the January 2013 edition of the Journal of American Medical Association, clinicians focused on enhancing care coordination efforts. Among patients that participated in the study, readmissions declined by 5.7 percent, compared to 2 percent in communities where robust care coordination efforts were not utilized. The study further projected that in a community of 50,000 Medicare beneficiaries, Medicare could save $4 million annually on readmissions for every $1 million spent on care coordination interventions.2 Other use cases and studies further underscore the importance of care coordination in improving quality of care, enhancing patient satisfaction and lowering overall cost of care.
Clinically-Led Care Coordination Team
Most successful care coordination models include nurses, social workers and other ancillary support members. While lay "navigators" or "coaches" can also play a role -- particularly in supporting specialized community subsets -- the ability to assess, intervene and collaborate with the primary care provider, specialists, the patient and family necessitates a clinically-led team. In fact, a robust care coordination team is actively managing care plans, providing clinical guidance, and proactively tracking and managing the patient for an extended period of time.
Making Coordinated Care Scalable
For the team to be cost effective for all providers -- not just large physician groups or health systems -- a centralized care coordination model is essential. Many providers find that building a care coordination team and associated infrastructure is a major undertaking best left to outside experts. In the centralized model, care coordination is delivered by a firm specializing in Population Health Management. The team operates from a primary location and care coordinators identify themselves as part of a specific physician's care team. In fact, this centralized team is a critical component of the medical home, augmenting the primary care provider care team to proactively manage patient care.
Ideally, the team is working from a Population Health Platform in which a single silo dashboard tied to the EHR delivers alerts, identifies gaps in care, contains care plans and case management applications, and is accessible to the entire care team.
Learn more about the centralized care coordination model by downloading a free case study. To discuss how Continuum can enable coordinated care for your organization, please contact: Devon Swanson, (856) 782-3300 ext. 2419 or firstname.lastname@example.org
1 McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 2, Background: Ongoing Efforts in Care Coordination and Gaps in the Evidence. Available from: http://www.ncbi.nlm.nih.gov/books/NBK44011/