As healthcare consultants, we are often asked to help a relative or friend navigate the healthcare system to obtain appropriate and effective care. Without this assistance, too frequently patients are lost to follow-up, tests are duplicated, care plans are not followed, referrals don’t lead to timely specialist care and medications are not taken on time or in the correct dosages. All of these failures lead to poor outcomes, excessive costs and a bad experience for both patients and providers. Multiplying these suboptimal experiences across the healthcare system, it’s easy to see that the time is right for care coordination enabled by health information technology (health IT).
Care coordination is a formal way to address these issues by assigning a specific individual to the job of helping guide patients through the maze of diagnostic, care and treatment activities required to execute their individual plan of care. A care coordinator may perform this task as only one part of his or her job, or care coordination can be a full-time assignment. Care coordination can be performed in an individual physician practice or it can be a service provided by a health plan or other agency. The Veterans Health Administration actively coordinates care across various care settings using dedicated care coordinators who are usually nurses or social workers. Typically, an individual care coordinator manages a panel of between 100 and 150 general medical patients.
In a recent article, Marjie Harbrecht, MD, CEO of Colorado-based HealthTeamWorks, describes care coordination and also highlights the role of health IT. She defines care coordination as “[focusing] on tactical issues: using patient registries to ensure that individuals and specific patient populations (e.g., diabetics) get needed services, tracking lab tests/referrals and naming a point person to manage information flow in and out of the practice…[A] key tenet…is to coordinate care across the medical neighborhood of providers, which includes referrals to specialists, imaging centers, physical or occupational therapists, mental health providers or community resources.”
Technology enables care coordination in community practice settings, where a computerized registry and electronic health record (EHR) are very important tools to assist the care coordinator with essential activities. These include ensuring that all necessary results and reports are available for the care team, reviewing the assessment and treatment plan, and completing evidence-based guideline recommendations.
The Veterans Health Administration has taken the use of computerized tools to a much higher level, and provides a model that other practices can use once the necessary payment mechanisms are in place. The agency uses health IT extensively to support coordination across the continuum of care, ranging from the hospital to the home. Their health IT program includes not just an EHR and registry, but also real-time telemonitoring technology.
Care is actively managed by full-time care coordinators. Every patient is formally assessed by his/her care coordinator upon enrollment in the program. Once a patient is enrolled, the care coordinator selects the appropriate home telehealth technology, gives the required training to the patient and caregiver, and communicates with the patient’s physician. The patient’s underlying chronic condition is used to determine which technology is needed. Possible technologies include videophones, messaging devices, biometric devices, digital cameras, and telemonitoring devices. Messaging devices present disease management protocols, including text-based questions for patients to answer. Responses help assess a patient’s health status. Biometric devices record and monitor the patient’s condition, including pulse, temperature, blood pressure, oxygen saturation, weight and blood glucose levels. Videophones and video telemonitors support audio-video consultations in the home, which replicate face-to-face examinations.
This data is accessible on the care coordinator’s desktop computer for follow-up. Each individual patient is risk stratified daily through color-coded alerts that indicate significant changes in any patient’s symptoms. Once patients are identified as “at risk,” care coordinators get involved to prevent hospital admissions and emergency department visits.
The cost of the Veterans Health Administration care coordination program, including home telehealth monitoring, is modest: $1,600 per year per patient, which is substantially less than other programs. Moreover, the program is effective. Quality and performance data from a cohort of 17,025 patients showed a 25 percent reduction in numbers of bed days of care, a 19 percent reduction in numbers of hospital admissions and a mean satisfaction score rating of 86 percent.
Care coordination is a necessary addition to the arsenal of tools used to advance the country’s goals of improved outcomes, reduced healthcare costs and a better experience for patients and providers. Automation starting with registries and EHRs, but advancing to the most modern biometric monitoring and patient engagement tools, can contribute substantially to the effectiveness of these interventions.
Edited by
Alisen Downey
