According to a Care Redesign Insight Report, created by the New England Journal of Medicine, healthcare organizations are applying coordinated care services so differently that,“7% said their patients’ care was fully coordinated between various healthcare settings.” 

Today, patient-centered care must become the focus.

Health systems that successfully coordinate care towards their patients, have the proper resources, leadership, and culture to support communication and collaboration among teams of providers and specialists. This creates a continuum of care and a seamless path for patients as they navigate their healthcare journey.

Defining Care Coordination Services

In healthcare, care coordination services mean sharing information among all participants concerned with a patient’s care to achieve safer and more effective care. 

This means that a patient’s preferences are known and communicated at the right time, to the right people, with the care it deserves. Care coordination keeps patients healthier, helps properly manage chronic conditions, and supports care that is consistent with their goals  (Agency for Healthcare Research and Quality). 

When healthcare providers do not communicate effectively with one another, treatments prescribed by different providers might conflict or make the patient uncomfortable. A lack of coordination can lead to negative health outcomes for patients, excessive uses of emergency care, medication errors, and poor medical transitions. 

Some examples of care coordination services are:

• Creating a proactive ‘care plan’ and sharing it with family.
• Helping coordinate transitions of care, like from hospital to hospice.
• Monitoring, following up, and responding to changes with patient needs.
• Actively working to align organization resources with patient engagement.

Benefits of Care Coordination Services

Well-designed care coordination is an important part of providing quality care. This involves organizing and managing resources necessary so that patients receive the best possible care. Here are some of the main benefits of having dedicated care:

• Improved patient outcomes. 
• Reduced healthcare costs.
• Enhanced patient satisfaction.
• Smoother healthcare experience.

Care coordination is a key element to ensure that all members of the healthcare system, including the patient, understand their roles and are actively working towards shared health goals. This also offers peace of mind in knowing each member of the healthcare team understands their individual tasks.

When it comes to care providers, care coordination allows for greater patient outcomes due to better communication and collaboration between different healthcare teams. This reduces medical errors because each member of the team is kept up to date on the patient’s progress. Also it increases efficiency in the overall system of care as all members of the healthcare team understand what needs to be done when it comes to a treatment plan. This helps reduce costs associated with unnecessary tests or treatments that may occur when there is insufficient communication between healthcare providers. 

Challenges and Barriers

It’s clear that care coordination is essential for health systems to thrive, but there are still many hurdles the healthcare system faces when trying to perform this continuum of care. Communication gaps, data sharing, and interoperability issues are common due to the disjointed nature between primary and specialty care sites. Health organizations that operate at different levels often don’t communicate, and this can leave a patient and their family feeling lost or isolated at such an important time.

In a recent whitepaper, CareXM took their knowledge of value-based care a step further and spokes to the importance of care coordination by describing real challenges patients face today:

“When patient-customers call, they do not want to wait 33 minutes to relieve their anxiety, get medication-administration assistance, or get a simple question answered. That is not a continuum of communication, comfort, or care, and typically leads to more 911 calls and costly ER visits. Instead, they want their phone call routed to and answered by the person who can help them the most quickly. 

Likewise, our clinician-partners do not want to interrupt patient care to handle communication issues. They want up to date, coordinated information, documentation, and communication – or even real-time patient data. They want to be able to see assigned tasks and completion status. They want to reach patient’s caregivers more quickly and do not want to use their tired, emotional selves to effectively portray a patient’s situation. They want data to help ensure the continuum of care” (The Quadruple Aim, 16).

Innovative Approaches

Groundbreaking care coordination ensures that care from different providers is thoroughly communicated. There are many innovative technologies, tools, and strategies that can be used by healthcare organizations to facilitate care coordination. At CareXM we have employed a few into our approach to create a continuum of care.

• Electronic health records (EHRs) are built to share information with other health caregivers and organizations like specialists, pharmacies, and emergent facilities. CareXM systems integrate with most up to date technology so we can provide up to the minute information.
• Telehealth services bridge the gap between patient and provider. Features like patient call analytics, secure messaging, intelligent call routing and staff availability tracking can all be employed for a continuum of care. 
• Patient portals are secure, online portals that allow patients a convenient 24-hour access to personal health information. They enable patients to securely message their doctor, request prescription refills, schedule non-emergent appointments, view educational materials, and make payments.

Interprofessional Collaboration

Full communication between healthcare staff is the first step to improving the quality of care for both patients, family, and caregivers. That’s why performance sharing is a great way to span the continuum of care coordination. Obviously, patient data requires high confidentiality, but performance can be mapped out across caregivers. Communication makes it easy to see where a patient’s healthcare journey is going and how each staff member can collaborate to help best. Essentially, collaboration puts patient performance into context, and without context, it is impossible to know where to go next. Interprofessional collaboration will always allow improvement because each healthcare provider plays to its own process, challenges, and strengths.

Real-Life Case Studies

At CareXM, coordination of quality care is in our bones. Our mission is to care–about the patients, staff, and business of our healthcare partners. We help you extend your level of care. At Goshen Health, we did just that.

Goshen Health is a 3,000-employee magnet hospital. The director of home care and hospice decided her organization needed to prioritize care coordination and partnered with us. She chose to leverage business intelligence platforms and outsourced after-hours triage to take care of “things that matter the most.” 

Goshen’s action plan to improve the patient and clinician experience:

1. Focus on people, processes, and a continuum of care that could be taken with patients no matter where they went.
2. Engage in CareXM triage and technology for better communication.
3. Restructure, convert part-time employees to salaried, full-time employees with productivity expectations.

After some time, exciting results began appearing:

• Patient complaints stopped.
• Overtime expenses dropped 70%
• Significant reduction in after-hours calls.
• Notable improvement in clinician documentation & virtual mentoring.
• Savings allowed for more full-time case managers, evening, and weekend staff.

According to the director, Rebecca Alexander-LaBroi, “CareXM has been worth its weight in gold and moved us toward our goals in patient satisfaction related to response times and colleague work-life balance”.

With CareXM you gain an experienced, clinical partner you can count on to deliver the help you need to elevate your patient and caregiver experiences. If your goal is to create care that impacts everyone around you, we would love to show you our approach to continuums of care. 

Whether you need after-hours triage, our cost-saving hybrid triage solutions, or in-house triage call-center infrastructure, we help you flex and extend your care, so you reach patients in the moments they need help the most. From home health and hospice to health systems and more, CareXM will transform your triage to lower operating costs. reduce burnout, improve outcomes, and elevate the patient experience.

Let us extend your care coordination services today.