The idea of coordinating care to improve overall patient outcomes is certainly not a new one. Just ask the nurses who have influenced the evolution of care coordination for more than a century.

With the essential knowledge and expertise to improve healthcare, nurses have been integral to its progression. Until recently, the activities of the care coordinator often remained invisible and failed to advance because the value that care coordination added to the organisation did not directly equate to a revenue stream. Now, with recent legislation enabling payment for chronic care management in addition to transition management, care coordination is becoming more and more central to a value-based and patient-centred care model.

Paving the Way for Successful Models of Care Coordination

At its core, care coordination includes effective communication, collaboration with care team members and families, patient education, advocacy and care planning. There are many successful care coordination models that have been implemented and led the way to exemplary care, including Project RED, Medicare Coordination Care Demonstration (MCCD), and GRACE, to name a few. With the documentation of outcomes from these programs, studies are showing a range of positive quantitative results including decreased cost and length of stay for hospitalised patients as well as increased satisfaction.

The Shift to Care Coordination as an Exemplary Model of Care Delivery

Care coordination is finally getting the spotlight it deserves as we are currently seeing the alignment of technology, financial incentives and new regulations that truly incentivise organisations to move toward care coordination as a model for care delivery. In January of 2013, Medicare initiated payment to qualified physicians and non-physician professionals for the delivery of Transitional Care. In early 2015, payment was expanded to include reimbursement for Chronic Care Management for non-face-to-face services to qualified beneficiaries. Medicare’s ruling to reimburse for these care coordination services is necessary to further ensure the continuation of this model to improve overall health and healthcare at a population level.

What’s Needed Now is Increased Interoperability

The efficient exchange and sharing of health data is a key feature of coordinated care. This exchange, however, is often hampered as health systems acquire new hospitals and physician practices that include both affiliated and non-affiliated physicians. In addition, the ability to share information across organisations has been difficult, where only 14 percent of physicians surveyed in 2013 were electronically sharing data with providers outside of their organisations. Until the healthcare industry removes barriers to interoperability, care coordinators will continue to take on the manual tasks of consolidating patient information to make effective patient recommendations.

To ensure the success of care coordination as a model for care delivery, healthcare organisations need to focus on building a technology foundation. To build this foundation, organizations need:

  • Integration of data from disparate systems in order to create a longitudinal patient record
  • Analytics to identify gaps in care and opportunities for population health improvement
  • Workflow tools that support care coordination among disparate teams and put actionable information into the EMR at the point of care
  • Patient-facing tools that empower patients to follow care plans, enabling real patient engagement
  • Scalable and flexible solutions to meet the needs of organisations

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