By Meghan Franklin
Even if you’ve never heard the term “care coordination,” you’ve likely noticed when it was done well. Just as likely, you have noticed when it wasn’t done well.
Recently, I learned my 18-month-old son has a tree nut and lemon allergy. He was diagnosed after an episode of vomiting and hives led me to call my pediatrician. New to the world of allergic reactions, I almost hesitated to pick up the phone. As a new mom, I worried I was overreacting. My son seems to be fine now, I thought, maybe something he ate just didn’t agree with him. Nevertheless, I called, and the pediatrician asked us to come in later that day.
After a short consultation and examination in the pediatrician’s office, the doctor referred us to an allergist and advised I get an appointment as soon as possible. She also wrote a prescription for an epinephrine injector, just in case my son experienced another, more serious allergic reaction.
While driving home from the pediatrician’s office, I received a call.
“Hello?” I said.
“Mrs. Franklin? This is Mimi from Colorado Allergy and Asthma. I understand your son has been referred to us and I’m calling to see if you’d like to set up an appointment.”
Wow, I thought. That’s incredible care coordination. Actually, I didn’t think that exactly at the time, but that’s exactly what impressed me and made me grateful for care providers who understand the importance of breaking down the silos in which care providers have historically operated. Before I got home, I had an appointment scheduled with the allergist.
Later that evening, I received a call from my neighborhood pharmacy to inform me my son’s epinephrine injector was ready for pick-up. This was thanks to electronic prescribing, which allows prescriptions to be sent directly from the ordering provider’s office to the patient’s pharmacy of choice.
About a week after my son’s appointment at the allergist, the physician’s assistant who saw my son sent a detailed letter to my home and to my pediatrician, summarizing her findings and the plan of care.
While this experience of care coordination may be a simple one, it made a difference to me and my family. The coordination between the pediatrician, the allergist, and the pharmacy improved our experience of care and helped ensure I took all the recommended follow-up steps as quickly as possible. The allergist’s follow-up communication after my son’s appointment also ensured my son’s small care team – his parents, pediatrician, and allergist – were all on the same page about the next steps in his care plan.
Care coordination can mean a variety of different things, but ultimately, it is a patient-centered approach that strives to meet the needs and preferences of individuals while strengthening the caregiving capabilities of families and service providers.
Other characteristics of care coordination include:
- Collaboration between all members of a care team, no matter their specialty, role or location
- Clear communication between all parties involved in a patient’s care, including the patient/patient’s caregiver
- Avoiding unnecessary and/or redundant tests and procedures, which can both improve the care experience and reduce the cost of care
- Assessing all of a patient’s needs – not just their immediate clinical needs
While there are certain elements of care coordination that are shared across healthcare environments and patient types, it’s not one-size-fits-all. While working at a top children’s hospital, the leader in charge of their care coordination efforts described it as delivering the right care in the right place at the right time. What’s right for one patient isn’t necessarily right for another, which makes care coordination more of an art than a science.
The type of coordination required depends on a number of factors, including the patient’s level of education; the complexity of their medical condition; their access to resources, including things like stable housing and transportation; and the level of ongoing care that will be required at home.
At some healthcare organizations, certain patients may even be assigned a “care coordinator” to help coordinate care. At that same top children’s hospital, for example, transplant patients are assigned transplant nurse coordinators. Nurse coordinators focus on helping patients and their families maximize the quality of life and help them navigate the complex care needed before and after transplantation. They serve as the hub in a multi-spoked wheel of caregivers that includes surgeons, anesthesiologists, social workers, psychologists, financial counselors, lab technicians, dietitians and other organ-specific specialists like hepatologists.
Why does care coordination matter?
When it’s done well, care coordination not only improves the patient’s experience of care, it also can improve health outcomes and reduce costs – all part of the Institute for Healthcare Improvement’s “Triple Aim”.
This “triple aim” is at the center of so much healthcare reform work, including the shift to a value-based reimbursement methodology, which rewards providers for effectively managing the health of individuals and populations.
Effectively managing the health of individuals and populations requires much of what care coordination requires: effective and timely communication between members of a care team; delivering patient education at the right level, at the right time, and in the right place; and creating care plans that treat not only the patient’s medical condition but also considers barriers that may prevent them from following through on their care plan.
In short, effective care coordination matters on a larger scale because it is essential to achieving the reform that all parties with a stake in the American healthcare system know is necessary.
Care coordination matters on a smaller, more personal scale because, as in my experience as a new mom dealing with her son’s first allergic reaction, it builds trust between the patient and their care team. It includes the patient/patient’s caregivers as part of that care team. And it helps the patient/caregiver feel empowered to contribute to a successful health outcome.
Meghan Franklin is a freelance writer who has worked extensively in healthcare, both as a writer and as a project manager.
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