Care Coordination 101: Evolving to Patient-Centric Care

Abhinav Shashank
Tue 18 Oct 2016
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The US healthcare is getting costlier every day, and it is without a doubt true that most of the US citizens live in fear that they won’t get access to the care when the illness strikes. The sad truth is that every year over 100,000 deaths occur due to medical errors. All this when we see horrifying figures even after adjusting the America’s higher per capita GDP; the US spends roughly $500 billion more than other developed countries.

The Problems with Coordination
13 years ago, way back in 2003, the Institute of Medicine had identified the most persistent problem in the healthcare industry, and it was coordination. The idea behind implementing EHRs was to create digital data that is easy to share, but that did not happen. According to a study, 63% of Primary Care Physicians and 35% specialist are not satisfied with the information they receive from other physicians within the adult referral system.


The above graph shows how poorly coordinated care has affected the adults. The US stands second when it comes to High-need patients. This is when the US spends over $10,000 on one person’s health.

According to a research article, the biggest challenges Primary Care Physicians and Hospitalists faced were:

  • Difficulty reaching out other clinicians
  • Lack of information feedback loops
  • Lack of general information like clarity on test results, history, and medications, etc.
  • Insufficient access to discharge information of patients.

Working towards a Solution

Besides these, a lot of problems arise when patients miss out on medications, follow-up visits or any other requirements. Thus, there is a need to create a process where neither do PCPs miss out on critical information nor does the patient stay unaware of the care plans. For this PCPs had identified the most successful care coordination components.

  • Better coordinated care for at-risk patients.
  • Enhanced direct contact with patients through phone calls.
  • Advanced use of EMRs for better health information exchange.
  • Developing better interpersonal relationships
  • Pre-defined accountability.

Health Coaches connecting Care

The most important aspect of healthcare is that when a care process is nearing its end, the patient should be in a better state. A patient-centric approach is must to make sure a patient gets the best treatment. Health Coaches ensure that the patients get what they need. They make sure that the

  • Patient doesn’t miss out on his medications
  • Patient attends follow-up visits,
  • Patient has no transportation barrier while visiting a hospital
  • Inform family/caregiver about the care plans and the patient
  • Track and make sure adherence to care plans
  • Review discharge instructions

The Three Pieces of Care Coordination

More often than not care coordinators miss out on the essential information about the patients. In worst cases, they have no discharge information of patients creating gaps in care and indirectly increases the cost of care. Ideally, the three pieces of care coordination together can bring dramatic improvements in patient-centric care. The three pieces are:

Relationship with Patient

A Health Coach would perform better when he has an interpersonal connection with the patient so that patient feels close to caregivers and trusts them. For this, a health coach should call the patient as soon as he is discharged and make sure the patient has all the necessities such as a caretaker, medications, transportation means, etc.

Higher Transparency Standards

A care coordinator should make sure that the patients’ records are up to date. The medical history of a patient, the conversation he had with health coaches, current medications, family/caretaker, upcoming visits, etc. When the patient moves to a new Primary Care Physician or a new care coordinator, his all information is available to them.

Care Plan Design

A care coordinator should take note of all the responses that a patient gives to specific questions related his health. Based on the elaborate survey and call with the patient, a care plan based on it for a month or two which involves a pre-defined procedure that has to be followed for holistic care of the patient to make sure the health of patient gets better and further readmission is not in the picture.

Success through Care Coordination

A Wisconsin-based Health system implemented a care coordination model and following were the observations:

  • The total reduction in charges was $6.5 million after the first year and $3 million after the second year.
  • Inpatient charges reduced by 55%.
  • For every $1 invested, $8 were saved.

In some cases, initiatives like phone calls reduced the ED visits by 52%. Over 20% reduced readmission rates in many organizations which implemented care coordination. For a Virginia-based value-focused organization, the readmission rate was below 2%!

The Road Ahead

Care Coordination is the missing puzzle of EMRs. The promise of affordable and equitable healthcare is within reach once we have a connected healthcare. One where a physician knows his patient better, one where patient understands the course of action, one which is affordable and in the end a patient-centric healthcare.

A care coordinator is a tackle covering the blind side of a physician, the quarterback making the success possible.

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Tags: Accountable Care, Healthcare
Abhinav Shashank
Care Coordination 101: Evolving to Patient-Centric Care

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