Care Coordination


Hippocrates arguably created the medical profession as a discrete art around 480BC and the first hospital in the United States was established in 1751.  However, the complexity of the medical system has reached a point where the traditional relationships between doctor, patient and community are being altered.  We’ve talked about this on the blog as Justin wrote about how to manage the profit cycle and I wrote in my previous post about how to treat a broken wrist.   A key to managing medicine in the modern age will focus on how to ensure proper care management – helping all of us to take advantage of the healthcare system without being overwhelmed by it.

Care management involves at least 4 key components:

  • Outpatient providers who are the “first line of defense” against disease
  • Hospitals which handle acute care
  • A patient’s home care team – both paid providers and the patient’s family
  • Payers who need to be able to show the ROI of the investments that they make

As you’ll agree, none of these components is new but we’re seeing the relationships between these parties change.  Healthcare IT is a core part of this transformation because it will enable more complete and seamless transmission of data.  The National Quality Forum has promulgated a set of guidelines for measuring care coordination and best practices that had a heavy emphasis on establishing effective transitions of care.

Given the complexity of modern care, the role of the hospital will never fade but hospitals may stop being the center of many patients’ medical experiences.   In the world of patient-centered medical homes, the outpatient providers become the focal point for scheduling the necessary care, directing collaboration among physician teams, and monitoring the patient care.   If we expand the definition of care coordination to include management of patient’s overall health, outpatient clinics are working with patients to offer a range of services to support care for common chronic diseases – everything from social services to nutritional guidance to mental health counseling.  This benefits patients both before they are admitted to the hospital but also when they are released from the hospital and need to stick to complicated care regimens.     (Those who are interested can find out more at the PCMH Resource Center with the Agency for Healthcare Research and Quality.)

Ambulatory providers also serve to coordinate care with the patient’s home care team.  This home care team can include both paid providers such as visiting nurses but also the unpaid members of the patient’s family.  Those who know the patient may best serve to monitor and coach the patient but also alert the primary care providers if something is amiss with the patient.  The telecommunications industry has spent a vast fortune trying to solve the last mile problem of getting accurate data transmission into people’s homes.  The medical profession needs to solve the same problem – not by laying additional miles of fiber optic cable but instead by ensuring that people in the home have full access to the patient’s records, the tools that they need to help monitor the patient, and the coaching to know when to call for help.  While there are some fantastic advances that are being made in terms of home medicine, one key characteristic is as old as Hippocrates – establishing trust between the patient, the family and the medical provider.

Of course, patients are always going to end up in the hospital.   A goal of proper care coordination is to reduce the number of times somebody needs to go to the hospital, improve their results while they’re an inpatient, and eliminate the need to readmittance later.  With more complete access to the patient’s records, hospitals are able to make more informed decisions and incorporate Healthcare Intelligence.  Steve Dion wrote earlier about the Medical Quality Improvement Consortium, GE’s database of 30 million (that’s 30,000,000!) de-identified patient records.  Such tools can help enable more informed benchmarking against other providers and the prediction of  clinical decision support.  Hospitals also need to be prepared to discharge a patient to their home care teams and outpatient providers in a way that helps to minimize the hiccups on transitions of care.

I won’t dwell on the payer side of the equation since we’ve spent a lot of time writing about that on this blog, but one of the challenges to healthcare IT providers such as GE is to help payers measure that they’re receiving an equitable return as the location and nature of patient care changes.

The challenges may be as old as Hippocrates but the solution to care coordination is to use our modern tools to help create a holistic view of the patient.



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