Highlighting the Value of Care Coordination

By Matt Phillion

Care coordination is fundamental to all care models, but as value-based care (VBC) models continue to grow and expand, there’s an even greater need for tools to help improve workflows, solve the care coordination challenge, and benefit patient outreach. Risk-bearing providers need a comprehensive set of tools to engage and work with patients according to their individual needs.

As the shift to VBC continues to accelerate, providers are looking for ways to streamline referrals, ensure alignment between primary care and specialists, and control network leakage.

“Care coordination, whether you’re VBC or not, is important—and whether you’re under VBC or not, it needs improvement,” says Lynn Carroll, chief operating officer for HSBlox, which recently launched a new care coordination tool. “What heightens the need when looking through the VBC lens is that a lot of alternative payment models are written with what we’d call a fixed reimbursement model.”

These models look not just at financial performance but also outcomes.

“On the financial side, there are incentives to ask: If I take a fixed reimbursement stream, how do I manage things effectively to not only achieve the desired outcomes for patient and provider satisfaction, but also then manage the financial performance? The two go hand in hand. How do you achieve both a good outcome and control costs?”

Ultimately, Carroll says, this comes down to not just care coordination, but also patient engagement to help make sure you’re deploying resources appropriately.

“A lot of these alternative payment models have a more global component to them,” he says. “If you have patients under that fixed component, a lot of the spending can be done in the specialty realm. If you have a primary care physician (PCP) responsible for the total cost of care for their panel—and that might be 1,500 to 3,000 patients, for example—a significant portion of that spending they don’t directly control, particularly with polychronic or multiple disease management.”

There may be several specialists involved, ordering different tests, prescribing different medications, or considering other types of treatments.

“That becomes the reason for the care coordination piece,” says Carroll. “How do handoffs occur? Are the care team members able to understand what’s happening with the patient at any point in time?”

The importance of workflows

To control both costs and quality of care, a starting point is: Where is your patient going next?

“Things always come back to workflows, and one of those workflows is referrals,” says Carroll.

For example, you go to your PCP, or maybe end up in emergency care. You receive recommendations for what to do next, whether that care is surgical or non-surgical.

“What happens is, depending on that diagnosis, the PCP probably refers these acute cases or polychronic patients to a specialist,” says Carroll. “There needs to involve not only a sharing of clinical documentation and notes in a timely, effective manner, but also providing any additional insights the specialists may want to be aware of, both medical and non-medical.”

Non-medical can mean anything that might impact the patient: social determinants of health, environmental conditions, employment, any other indicators.

“But when you start to get into that, you run into interoperability issues—not only in traditional delivery systems, but organizations that don’t typically use healthcare industry standard transactions,” says Carroll. “You’ve got to have a good workflow, a technology to support that workflow, and that can disseminate that information to the appropriate care team member who can then take action or at least be informed in an appropriate manner and time.”

This level of information-sharing and coordination can help lessen costs as well as stress on the patient by letting physicians track what tests have been done and determine if they really need to rerun a full battery of tests, or if they can rely on those ordered by the PCP or other physician previously.

“The danger of running duplicate tests isn’t just cost, but patient safety. Is it necessary to do another round of x-rays?” says Carroll. “There can be overuse in the continuum of care and on the technology side, we can make sure we know what other participants in that continuum of care have done.”

This allows for better managed or next-best step actions. It also enables providers to have a more holistic view of the patient along that continuum of care.

“For example, you might be enrolled in a diabetic management program, but next week you find out you need to have your hip replaced,” says Carroll. “In a bundled payment model, those two things are pretty far divorced from each other. Down one path you have your diabetes managed, but the hip replacement is another path, and you’re going to have a case manager or care coordinator assigned to you separately for them.”

Even in today’s highly technical, highly wired-in systems, it’s possible for cases to be managed in silos.

“One of the benefits of a good care coordination tool is ensuring that different case managers from different programs aren’t operating in a vacuum,” says Carroll. “These types of tools help providers understand the holistic tenor of what’s going on with the patient.”

Divergent technology, lack of communication

Perhaps the greatest barrier to improving care coordination is the technology we already use. Different teams or organizations are on different systems, and the age-old issue of interoperability raises its head. But things are headed in the right direction, Carroll notes.

“We’ve started to see a more centralized view of managing scheduling, for example,” he says. “We’ve seen this done really well with systems where specialists are all under one roof, but that’s not how most care is delivered. Some of the bigger systems have top to bottom integration, but if you think about some of the underserved markets where a lot of the population is using Medicaid, particularly in rural areas, it’s not there yet.”

So how can we work to connect the dots for better coordinated care and communication?

“Looking at this from a purely health system standpoint, they want to keep you as a patient forever,” says Carroll. “If you were born in a hospital and still live in that geographic area, they’d like to be seeing you as you continue to grow and age. The challenge comes when you’re in an open access program, a POS or PPO program where you can go anywhere you want, where suddenly the care is fragmented. You’ve engaged in care at one facility, and had some other things taken care of at another. That’s where patient leakage happens.”

Organizations lose revenue in this case, and the payment model can become complex, but who really loses in a disconnected system? Carroll asks.

“The patient,” he says. “They’re going to see uncoordinated care. Let’s make the assumption that a patient has 10 providers he’s going to see, and that they’re all appropriate for what he needs to see them for. Who has to tell each of them what’s happened with the other nine? The patient. And he’s not a trained medical professional. He can tell them, ‘Hey, this hurts,’ or ‘I can’t see well,’ or ‘I have a ringing in my ear.’ That’s what he knows.”

But it’s those other additional details a trained professional can provide that can be disconnected and uncoordinated. What were the exact previous diagnoses? What drugs have been prescribed?

“You have to be your own advocate,” says Carroll. “The type of coordination we need exists in other industries. If someone is going to build a home for you, they have subcontractors who do the electrical and the plumbing, while you as the consumer who is buying the home have one contact person to make sure that happens.”

The same holds true for air travel, Carroll points out. You’re not paying for each step along the way but rather the whole journey. Healthcare could follow a similar path.

“It’s simpler for the patient, but also simpler for providers. Setting the financial part aside, the two primary parties in healthcare are the patient receiving care and the providers giving it, and if you can simplify that set of interactions, they’ll be happier and the likelihood of better outcomes is improved,” Carroll says.

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.