A few years ago, just as I was starting a new role as care coordinator at Henry Community Health (HCH), an Accountable Care Organization (ACO), I was asked to consult with a patient who was causing some frustration for our clinicians and the pharmacy team. This patient was always out of her medicine before she was supposed to be, and she was calling the office or the pharmacy constantly.
When I met with this patient, she was very skeptical. She had multiple comorbidities, underlying mental health issues and a very poor support system at home. It took time to develop a relationship with her. Eventually, though, she started to bring her medication in, and we realized that she wasn’t taking it correctly at all – that’s why she was always running out of it. Part of the issue was literacy – the medication instructions were confusing to her – and part of the issue was anxiety and insecurity around her health. This patient was also frequently in and out of the emergency department.
I began to meet with this patient every week. We set up an agreement with her and the provider: She would bring her medicine in, and we would fill a dosing box. In the beginning, I filled it every week while she watched me. Over time, I began to teach her to fill the medicine box while I supervised, making sure she didn’t have any trouble. After four months, she was taking her medications as prescribed and no longer ran out of them. We also saw a dramatic drop in her emergency room (ER) utilization during that four-month periods and thereafter.
What changed for this patient? Was it simply that she was finally provided the kind of support she needed? Was it taking the time to educate her about her medication? Was it that we could identify other contributing factors, such as her mental health, that were inhibiting her, and connect her with behavioral health resources? Was it that all members of the care team – clinicians, pharmacists and other providers – were collaborating and transparently communicating on the treatment of this patient? Likely all of those things are what made a difference.
I consider that patient an example of successful care coordination, but unfortunately, her situation is not unique. There are plenty of other cases just like hers – and to truly make an impact, we have to think about care coordination from the ground up.
Talk of care coordination is popular in the health care industry right now, particularly in the context of value-based care. We’re increasingly seeing a variety of new roles crop up in health systems to meet this trend; our outpatient care coordination unit was developed because the need was recognized, and my own position has since changed.
But what do we mean when we talk about care coordination? One definition positions it as “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services” – and this is certainly true. But to truly impact patient outcomes, care coordination has to start before the care team is in place. It has to start with the patient.
For an accountable care organization to really be successful, care coordination needs to be individualized. That means looking beyond the data and seeing whose health care costs need to be improved, whose engagement could be increased and whose satisfaction could be enhanced. That’s where we started.
If I've learned anything, it's that population health and care coordination isn't just a cookie cutter technique that works for everyone. Health care organizations should assess and understand the populations they are attempting to serve before strategies are developed and plans put into place. That means assessing the community and knowing what the needs are. Then comes the goal-setting – but the goals should be tailored, too.
There’s more than one way to implement a care coordination strategy. The difference is knowing your organization and the population it serves, and identifying where there are gaps in care where there is the greatest opportunity to make a difference.
Looking at the specifics of each population lets an organization discover and zero in on the specific challenges surrounding care delivery. Some common challenges faced by health care organizations today include:
These are some of the big areas health care organizations can look to improve with a comprehensive care coordination strategy.
There were over 4,000 patients listed in the ACO and attributed to HCH. I knew I couldn’t interact with 4,000 people effectively, so the process of finding out who needed our help the most began with a lot of risk stratification.
I looked at patients who had a history with those main challenges – high readmission rates, inappropriate ER utilization and a history of non-compliance – and found the common denominators. That left me with a list of 200 patients that I felt needed help with their care plan, and as an organization, we were responsible for coordinating their care.
Once I had my list, the grassroots campaign started. I began to reach out to those patients, trying engage with them, develop relationships with them, and see where I could help.
We talked through their issues. For the people that were going to the ER but weren’t seeing their primary care doctor, I tried to get at the bottom line: Was it a transportation barrier? Do they think they can get better service in the ER? I tried to redirect that behavior by identifying resources and educating them on transportation and scheduling options, but first I had to get patients to trust me and be open about their barriers – and that meant interacting with each patient one at a time, at an individual level.
Sometimes it wasn't just the patient who had an issue – depending on where they were in their health journey at the time, some of the care coordination needed to be handled with the family or the caregiver. There was a lot of telephone outreach and a lot of face-to-face outreach. I met patients in the emergency department, when they were admitted to the hospital and at their doctor's appointment – wherever I could make a face-to-face connection.
Grassroots care coordination is what our patient population needed. When we connected with people, we could get at their underlying problems – particularly if there were any insecurities or mental health issues.
Care coordination can’t work without data transparency and interoperable systems. This ties back to that challenge of a complex health care system that can become unnavigable for some patients: when health care technology is not interoperable, it makes communication between care team members difficult, which can be detrimental to the patient experience.
Case in point: When I started at HCH in 2014, our hospital system was on one electronic health record (EHR) and our office was on another, and neither system spoke to the other. That initial census I had of 200 patients was on a spreadsheet with notes that the clinicians couldn’t see, so any documentation happening on the outpatient side wasn’t viewable by the inpatient side. There was no transparency for what I was doing, and sometimes that meant the patients I was coaching were getting double – and sometimes contradicting – information from others on their care team. That kind of issue is difficult for health care providers and deeply frustrating for the patient – and it’s a roadblock to successful care coordination.
We’ve moved into a single interoperable EHR at HCH. This empowers our outpatient care coordinators, social workers, the ER utilization management team and clinicians to work collaboratively across the care continuum. There’s transparency, so we can all see who's involved in the care team of a single patient. That's value beyond measure! For an organization to do population health and care coordination and do it well, there must be good communication and good collaboration.
Cerner CommunityWorks is focused on involving patients in their own health. By leveraging our technologies, your hospital can shift from reactive care to proactive health management and your patients are able to take control of their health. Learn more here.