We have apps and software to manage it, new models of care and payment to encourage it across all levels of the care continuum, new ways to measure its success, and new penalties when providers or organizations fail to deliver it.
Care coordination has been at the foundation of hospice care since it was signed into law in America in 1982.
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Care Coordination Definition
There are differing opinions of what constitutes care coordination, but this definition seems to be widespread:
Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.
Hospice has proven the value of care coordination. Hospice patients may transition from an ICU or have spent years going from specialist to specialist, being hospitalized for exacerbations only to return to a healthcare plateau and a false sense of functional stability.
Difficult Cases Made Simple and Effective
Hospice patients are not simple cases. Yet they are moving from curative to palliative care—often from intensive and costly care to comfort care; always from disease-focused care to patient-focused care. Hospice must address the whole person quickly and efficiently.
Hospice takes a team approach, visiting the patient in the home.
- The whole team gets to know the patient, family/informal caregivers. They identify wishes and priorities, any religious or cultural expectations, household routines, individual capabilities, etc., to develop a plan of care
- The physician and RN determine the diagnosis and identify and manage symptoms
- The social worker and chaplain address financial and spiritual needs and psychosocial issues, often suggesting available community services/support
- The hospice aide is the most frequent visitor, bringing hands-on personal care to the patient
- A hospice volunteer and holistic specialists are assigned to meet the patient’s unique needs, from respiratory therapy to reading, from patient pampering to pet visits
- A bereavement specialist continues to call on family for more than a year following the death
These varied team members rely on communication, documentation, devices that allow real-time information sharing, and respect for one another’s professional expertise to ensure the appropriate delivery of healthcare services.
Medicare Keeps it Value-Based
It has worked for 35 years. Hospice services are a Medicare benefit, reimbursed in the same way to all providers, much as the ACA and its various models of payment propose to reimburse value-based care.
As in hospice, patients are most vulnerable during transitions: from one hospital shift to the next, from one specialist to the next, from one location or diagnosis or insurance company to another.
As in hospice, one entity is the care coordinator, ensuring all providers share information, understand their roles, keep the patient informed, manage referrals and transitions, and provide the right care in the right place at the right time.
As in hospice, the care being coordinated goes beyond clinical, involving psychosocial care, financial, educational and holistic.
The alternative is familiar to anyone providing curative care: medical errors, unnecessary diagnostic testing, unwarranted ED visits and hospital admissions, high medical costs and low-quality care are the current continuum of care.
To see how care coordination works over the long haul, look to hospice.
The Challenges: Transitions, Complexity
All patients are at risk when they transition—between providers or insurance companies, out of the hospital, onto a new prescription, etc. Patients with serious progressive illness are even more vulnerable. Hence the statistics for readmission of Medicare patients to the hospital: Due to complications, nearly one in five Medicare patients discharged from the hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of over $26 billion every year. (Meyers et al., 2010)
The complexity of these patients’ care can be addressed with care coordination. They may have multiple chronic or acute health problems. They may see multiple care providers in multiple locations. They may be unable to organize their own care, from keeping appointments to buying and taking prescribed medications. They may face social challenges, from isolation to financial hardship.
Where once their primary care physician coordinated their care, increasing complications mean increasing need for a care team that proactively coordinates care on a patient-by-patient basis. This is the interdisciplinary team approach used by hospice and palliative care.