What is Care Coordination?
Care coordination is the effort by multidisciplinary teams of two or more providers working with the patient to facilitate appropriate delivery of healthcare services to improve quality of care and reduce hospital admissions. (Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun)
The Problem: Fragmentation
The cost of caring for people with complex medical needs is spiraling out of control. We spend 17.6% (and rising) of our GDP on healthcare. The WHO ranks the US #1 in healthcare expenditures, yet our healthcare system is in 37th place behind Canada and Costa Rica. Most of these healthcare dollars (84%) were spent on chronic illnesses…increasingly being treated in the outpatient or home setting. Such treatments are inadequate and a fraught with insufficient care coordination, resulting in poor care quality.
The typical Medicare beneficiary sees 2 primary care physicians and 5 specialists across 4 different practices; 50% of these folks are being treated for 5 or more conditions. Over 19% of beneficiaries are readmitted to hospitals within 30 days of discharge. These are the “complex need” patients that face high risk for fragmented and inadequate care, resulting in poor outcomes. Many readmissions to hospitals can and should be avoided to save our tax dollars to the tune of $25 Billion each year.
What conditions and factors contribute to these high readmission rates?
The top conditions are: heart failure, COPD (lung disease), psychoses, intestinal problems, and post-surgical patients (cardiac, joint replacement, or bariatric procedures).
The top factors are: access to care post-discharge, inadequate discharge instructions, medication reconciliation, poor communication with and record transmission to care providers, medical errors in hospital. Elders report problems with their medical care including medical errors 23%, poor communication 20%, readmission 15% and lack of follow-up 6% (AARP, 2009).
The Solution: Care Coordination
Beyond upgrading discharge processes, which many hospitals are in process of doing, patients need timely access to care in the community through Care Coordination and using telehealth technologies to transmit clinical data to providers and to exchange information to facilitate their self-management (National Priorities Partnership).
Care coordination keeps patients on their care plan for follow-up visits and tests, medication, diet, and exercise. Old habits die hard and a care coordinator can help keep patients on plan to avoid setbacks, hospital readmissions, and ultimately higher health care costs. Through care coordination, the providers will engage the patient by viewing the patient as a whole, and giving the patient-client the opportunity to drive the course of their care plan and coaching them along towards better health. If done well, the patient will experience continuity of care and communication as they move from a healthcare facility to home.
This is not new. The idea of coordinating care in the form of case management has been around for more than a century. Primarily practiced by nurses and social workers, its goal has always been to coordinate complex, fragmented healthcare services to meet client the needs while controlling their costs (Nurs Outlook. 1996 Jul-Aug;44(4):169-72. Kersbergen AL).
This goes beyond redux….as care coordination is supported by Obamacare! Provisions in the Affordable Care Act 2010 give financial incentives to primary care providers for their care coordination services that are value-based; and penalize hospitals for high readmission rates. As research grows on how this can be done in a cost-effective manner, it is the hope this practice will spread to providers and hospitals. Medicare could save $188 billion in spending through 2019 by preventing avoidable readmissions, based on early research from the Congressional Budget Office.
HAS Case Study:
Our 48 year old male, diagnosed with Type 2 Diabetes on insulin, heart disease, and depression, recently lost his job and health insurance. With limited resources to care for his family, he could no longer afford the $800 plus monthly cost of medications and stopped taking his them. His blood sugars soared to 400-600 range, risking serious complications and hospital admission. When they came to us, the wife was distraught and overwhelmed. We obtained a stop-gap supply of insulin, test strips and syringes from a local charity and a few days later his sugars were lowered to low 200’s. We also guided him on his unemployment application. Now on Medicaid, the couple feels more encouraged about taking further steps with nutrition education and our health coaching.