As Care Coordination Expands, The Question Remains: What Does It Mean?
By Richard Scott
May 8, 2012
In the midst of healthcare transformation, with models like the medical home sprouting in primary care practices across the nation, the tide of popular opinion coalesces around a hard kernel of truth – namely, that bolstered care coordination is an express lane to cohesive care and more salutary outcomes.
The only difficulty is identifying precisely what that means: what, exactly, does care coordination look like? Better yet, what does it mean?
“If you ask that question of five different people in healthcare, you could get five different answers,” says Patrice Sminkey, CEO of the Commission for Case Manager Certification, a national nonprofit that certifies case managers.
The question is not lost on federal thought leaders, who are spearheading care coordination-intensive delivery models like the medical home by funneling millions of dollars to local providers in a quest to expand and unify their clinical processes and care measures.
After the passage of the Affordable Care Act, the Agency for Healthcare Research and Quality (AHRQ) published a comprehensive tome known as the “Care Coordination Measures Atlas” to examine how “this vital activity is or is not occurring.” As part of its efforts, AHRQ sought to define care coordination. This is what it came up with:
“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 marshalling 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.”
Since the Affordable Care Act was enacted, care coordination has come to be viewed as something of a magic bullet, and it is changing the fabric of traditional healthcare interactions and the roles of professionals involved in new models.
“The advent of new models of care under health reform – in particular, the medical home and accountable care organizations – have thrust care coordination center stage,” according to “Cultivating the Accountable Case Manager,” a report from CCMC, which continues: “And that changes the provision of care. Patient-centered care has expanded to include the patient, the family and the patient’s social network. Likewise, care delivery has expanded; multidisciplinary care teams deliver care across a continuum, and managing transitions of care across various settings has become an essential part of care delivery.”
According to Sminkey, case managers serve a key role in delivering effective care coordination. “What we try to do at the Commission is provide consistency in assisting the industry in defining what is care coordination, who is providing it, [how it is a] team-based approach, and looking at the board-certified case manager as a proxy for supervising the team,” says Sminkey. “We recommend that those teams and that care coordination be under the watchful eye and management of your case manager.”
Defining the Roles of Medical Homes
Medical homes are known to be physician-led enterprises. But they are also dependent on the collaborative work of the surrounding team members – including nurses, case managers, health educators and other key support staff.
“From the vantage point of the PCMH, care coordination is a core activity,” said David Meyers and fellow authors in the AHRQ report “The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care.”
The report considers there to be six key elements of care coordination, and goes on to provide definitions of each individual element. According to Meyers, the six primary characteristics of care coordination are:
- Determine and update care coordination needs. Care coordination efforts encompass the entirety of the patient’s needs, including physical, psychological and social factors. Good care coordination takes a patient’s wishes and desires into account. And care coordination assessments should be updated to converge with a patient’s changes in health status.
- Create and update a proactive plan of care. Working alongside the patient, care coordination professionals should outline a plan of action that incorporates a patient’s current and long-term needs and identifies any potential gaps in adherence to the plan. The care plan describes who is responsible for helping to achieve the expressed goals, whether that be the physician, case manager or other professional.
- Communicate. Comprehensive communication is essential. This includes talk, discourse and other communicative means across the following relationships: a) between healthcare professionals and patients; b) within teams of healthcare professionals; and c) across healthcare teams or settings.
- Facilitate transitions. The point in the care plan where gaps are prone to rear their quality-busting heads, transitions of care are of paramount importance to care coordination efforts. A good example is the transfer of information about a patient and his/her medical history from an inpatient setting to a skilled nursing facility.
- Connect with community resources. Care coordination involves community-based assistance that may exist outside of the healthcare system. Services may include social services, educational resources, support programs or financial resources.
- Align resources with population needs. Population health is a big part of care coordination services, and, when addressed, common gaps in care can result in large-scale improvements in the functioning and wellness of big patient populations.