Successful care coordination programs employ a variety of tools to improve quality of care and reduce costs. To be effective, these programs must be flexible in design, implementation, and evaluation, rely on robust data sharing, incorporate patient engagement, and adapt to local needs.

In addition, they must rely on patient goals, experiences, and feedback. If care coordination is properly targeted, and uses a well-designed intervention and fee structure, it can diminish undesirable outcomes such as re-hospitalization or avoidable emergency department visits.

An important distinction between traditional condition-specific disease management programs and complex care management is the use of specially trained, multidisciplinary teams who coordinate closely with primary care teams to meet the needs of patients with multiple chronic conditions, advanced illness, or other medically complex issues.

“Appropriate care is care that is both medically appropriate, as well as in line with a patient’s own health goals and priorities.”

Consider the following components to be necessary building blocks that help guide a successful care management program and address some of the elements that pertain to high risk populations:

  • Identifying the Target Population: Healthcare costs are highly concentrated in a very small patient subpopulation. However, not all high-need, high-cost patients are the same. In using predictive modeling tools, it is important to look at prospective risk scores, along with monitoring individuals whose risk scores are trending up over time.
  • Patient and Family Caregiver Engagement: Patient and family caregiver engagement involves forming meaningful partnerships and building trust at all levels of care delivery. Examples include shared care planning, patient involvement in system design, representation of patients on governing boards, and the establishment of relationships with community-based organizations. Motivational interviewing is an important technique to elicit a patient’s goals and desires that in turn supports more effective engagement and participation. In addition, patients should be afforded the opportunity to provide feedback on their care and understand how that feedback is being utilized.
  • Health Assessments and Screening Tools: A Health Assessment (HA) is a tool that provides the care team with insight on the quality of life and healthcare condition of its patient. The assessment should include the physical and behavioral health of a patient, especially conditions that are often comorbid (e.g., chronic pain and depression). Standard tools include the SF-12 (or VR-12) health status survey and the PHQ-9 for depression screening. Other tools such as the Patient Activation Measure help assess patient self-efficacy and assist care managers in tailoring their communications to the readiness and understanding of the patient. In order to provide a comprehensive assessment of the patient’s health environment, the initial intake should address safety, functional status, social and vocational needs, socioeconomic factors, personal preferences, and the ability of the patient to obtain necessary services.
  • Team-Based Care: Care managers are responsible for developing care plans in partnership with patients, monitoring ongoing symptoms, building continuity of care, reviewing patients’ claims data, laboratory reports, and prescriptions, engaging with patients to manage their own health, and working with patients and providers to set treat-to-target goals. In some arrangements, care managers are employed by an insurer, but are “embedded” in physician practices, or even emergency departments, in order to better coordinate care by interacting directly with patients and providers. A care manager may often be a nurse, with support from social workers, behavioral health specialists, pharmacists, or community health workers. Pharmacists are especially important in reducing readmissions by assisting with medication adherence and optimization for patients. Pharmacists employ strategies for providing and transporting medications to patients, working with patients to resolve medication-related issues, polypharmacy review, and educating patients and family caregivers on the patient’s medication regime and the importance of medication adherence.
  • Care Coordination and Infrastructure: Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective patient-centered care. This requires effective communication between providers, patients, and family caregivers, utilizing the patient’s language and other communications preferences, and an interoperable infrastructure to enable the transfer of clinical information between care providers. Health information technology is an important enabler in supporting team-based care and can be an important patient engagement tool as remote monitoring and other functionality evolves.
  • Patient-Centered Care: Appropriate care is care that is both medically appropriate, as well as in line with a patient’s own health goals and priorities. This care is patient-centered and patient-influenced, requiring a collaborative approach between patients and their providers. Treatment option decision support, including the use of formal shared decision making tools, should be offered to patients considering preference-sensitive procedures. Patients should receive no less than the care they need and no more than the care they want, in a timely manner.
  • Health and Disease Management Programs: Disease management programs are designed to improve the health of persons with specific chronic conditions and to reduce healthcare service utilization and costs associated with avoidable complications, such as emergency room visits and hospitalizations. Patients are commonly stratified into three or four levels based on risk. Those identified to be at the highest risk level are often appropriate candidates for complex care management, while those patients at moderate risk or low risk may not require as intensive intervention. Programs for diabetes, asthma, and congestive heart failure are the most common.
  • Transitional Care: Transitional care encompasses a broad range of “time-limited services designed to ensure healthcare continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another.” Education of patients and family caregivers is critical to the success of transitional care.
  • Quality Measurement and Evaluation Framework: Common metrics and monitoring processes for those metrics, both quantitative and qualitative, are critical to meaningful and effective evaluation of the success of a care management program. Beyond traditional HEDIS clinical quality measures, it is important to incorporate health outcomes measures such as changes in-patient health status and function, as well as patient experience. Utilization measures such as avoidable emergency department visits or primary care sensitive admissions can also be important indicators of program impact and potential cost savings.

Source: Healthcare Transformation


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