Putting Care Coordination into Practice

In the new era of value-based care, ensuring patients receive the right care at the right time from one end of the care continuum to the other is essential for achieving positive health outcomes and preventing hospital readmissions. Care coordination is one method of achieving this goal. According to the U.S. Department of Health & Human Services Agency for Healthcare Research and Quality (AHRQ), coordinated care “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 care.” But how do providers put coordinated care into action? “It’s all theoretical to some extent,” said C. Anthony Jones, CEO and founder of health technology platform Frontive. “You have all these people in different locations interacting with the patient, and that should lead to a better diagnosis and better treatment and better follow-up. That’s the goal. Each provider is making the best decision with the information available. … It’s not complicated in theory. It’s extraordinarily complicated in practice.” The caregiver technology platform CareLinx recently launched Medicare at Home as a means of enhancing care management and care transitions for Medicare Advantage enrollees. In 2019, the Centers for Medicare & Medicaid Services (CMS) will be offering approximately 600 more Medicare Advantage plans with expanded coverage for nonmedical homecare services, according to an agency press release. CareLinx meets the care coordination callenge head on. “When we receive the member eligibility file, we connect with a dedicated eligibility adviser at CareLinx. They educate the member on the total dollar amount and their eligibility within the plan,” said CareLinx CEO and founder Sherwin Sheik in a recent interview. “We try to match caregivers and members on multiple levels of compatibility—gender, language, extroverts, introverts.” Sheik said care coordination is bridging the gap between five major stakeholders in the industry: the family, the patient, the caregiver, the technical team and the physician. “Looping all five stakeholders into one platform in the home can reduce episodic care and rehospitalizations and increase patient satisfaction,” said Sheik about the Medicare at Home model. Currently, Medicare Advantage plans will pay for 200 hours of non-medical in-home care, and then the patient will need to transfer to higher-acuity care or find a means of private pay. The goal of Medicare at Home, said Sheik, is to provide a seamless transition into the private pay model.

Technology’s Role in Care Coordination

The role of technology in care coordination cannot be understated; however, the systems can still fail patients. Jones said, “Prior to information technology, everything was done verbally or on paper. But today, Epic doesn’t communicate with Cerner or AllScripts, and vice versa. Patients can choose to export their own records, but those records don’t easily flow into another system.” Jones said this could be concerning because a patient may choose a provider simply for the ease of data transfer rather than quality of care. “When data doesn’t seamlessly flow, it also puts a burden on the new provider. Without the prior record, the patient is essentially a blank slate who needs repeat tests to create a baseline.” Interoperability, the big buzzword in care coordination across the care continuum, is a major focus of PointClickCare. Interoperability helps the big EMRs communicate. But, said B.J. Boyle, PointClickCare’s vice president and GM of post-acute insights, “How do we make sure the person is at the center of care?” Interoperability helps providers understand the entire patient picture, said Boyle, in order to drive patient and caregiver goals. Boyle predicts that as interoperability increases, care will become less-facility centered. “We’re going to start breaking down the walls of where people are receiving care. Post-acute is going to become a critical part of the health care ecosystem, connected with the payers and hospital providers more than ever before.” The pressures of the silver tsunami drive care dynamics. Helping patients understand why one level of care is needed over another will drive better patient outcomes, said Boyle.

Communication Across Settings

In the home health setting, communication with the prescribing physician is crucial to the care of the patient. For patients with chronic obstructive pulmonary disease (COPD) and other chronic conditions, telehealth devices can help alert caregivers to problems before they get worse. Philips, a connected-device specialist, recently worked with a health system in Alabama to reduce COPD readmission rates through care coordination. “The patient may share what they recall about their health, but it’s not always the best information or complete. So, because the data is there from the connected care pathways, providers can make informed health decisions,” said Eli Diacopoulos, business leader of respiratory care for Philips. “We often forget that not only is the patient providing information, but also has a support network that is providing care—a son, a daughter, a relative—and also needs to record information and give this to the care provider, because the patient is not always going to remember everything. With more complete information, the physician is able to make more informed decisions for personalized patient care.” In Alabama, Philips had several stakeholders in the initiative, from the hospital to the home, including a preferred DME provider communicating data on the connected home ventilators and portable oxygen concentrators provided to patients. The data the DME provided allowed the physicians to make informed decisions for patient care, according to Diacopoulos. The Integrated COPD Care Initiative achieved an 80 percent reduction in 30-day COPD readmission rates over three quarters in 2017. Care coordination results in better care for the patient—when all parties communicate and work together. As more seniors intend to age at home, the need for better coordination will only grow. Better, more efficient record keeping, along with systems that allow information to flow freely will allow families, physicians and patients to make more informed health decisions and stay well, longer.