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Delivering Successful Care Coordination: Creating the IT Foundation for Accountable Care (Part Two)

October 6, 2013
by Joseph M. Taylor
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Part two of a five-part series on creating the IT foundation for accountable care addresses office and patient workflow-related issues

Last week, HCI Editor-in-Chief Mark Hagland interviewed Joseph M. Taylor, vice president and ACO practice leader at the Wayne, Pa.-based FluidEdge Consulting firm. Taylor, who is based in Dallas, works with a total team of more than 60 healthcare consultants, where he specializes in helping senior healthcare executives to prepare for and develop accountable care organizations (ACOs). Taylor has written a highly granular article, “Delivering Successful Care Coordination,” which the editors of Healthcare Informatics have decided to publish in five segments, in order to give our readers the full benefit of its granularity.

In the first section of the article, which followed Hagland’s interview with him, Taylor addressed the topic, “The key elements needed to identify and stratify patient populations.” In the second section, published here, Taylor addresses the topic, “The Office and Patient Workflow, Including the Role of Care Coordinators.” The remaining sections will be publishing in the coming days.

Joseph M. Taylor

The Office and Patient Workflow, Including Integrating the Role of Care Coordinators

An ACO patient may be assigned to a “Personal Physician” on the existence of only one office visit over the last 12 or even 24 months.  Generally, today a physician sees an “Attributed Member” or patient only when the patient reaches out and makes an appointment with that physician.  Many EMR’s are not loaded with full health history and the payer data is likely contained in a different system than the EMR if the physician is provided the payer data at all.  The Personal Physician may be provided a monthly patient “roster”.  Due to lack of process and staffing constraints prospective patient outreach is seldom undertaken.  In the meantime, life happens between those office visits.  The patient could have had no other health care interactions or they could have been to the ER, Urgent Care Center or even hospitalized.  The patient could have seen other doctors, been prescribed new medication and/or stopped taking existing medications.  They could have switched jobs, insurance companies or changed their diet and exercise habits.

On the payer side the scenario works something like this - After a 9 hour day of work, a 30-60 minute commute, and discussing the day’s events with loved ones, the “member” sees a letter in the mail in-between the car payment and the electric bill.  This letter describes “Friendly Commercial Insurance Company’s” care management programs that are “available” to use.  When the phone rings later that night during their favorite TV show or the next morning at work where co-workers may be able to overhear, the member is excited to answer the call.  The member can’t wait to discuss with some distant nurse that they never met before their entire health history and listen to the nurse’s predefined 45 minute script and questionnaire.  They are eager to improve their lifestyle and make significant changes right away.  After a few calls over the next few months which get missed and rescheduled, they achieve long term behavior change and significant improvement to their health status. 

Okay, so I may sound a bit jaded; however, neither of these two scenarios are far from the truth, and yet we wonder why things are the way they are. 

So what do we do?  We have to learn, embrace and understand the past and improve the current methods.  Successful physician driven, nurse executed, Care Coordination needs to understand today’s care management approach reality and incorporate the promise of tomorrow.  Today’s Care Coordination needs to change the paradigm or we will be destined to continue to achieve today’s results. 

It isn’t as difficult as it may seem to improve on today’s payer-based nurse call, member mailing care management approaches.  After identifying and stratifying the patient population (with the more robust and timely data sources discussed earlier), we have to leverage the greatest factor we have available to us today and empower it.  This greatest factor and largely underutilized factor by health plans is the physician/patient relationship.  In a physician driven, nurse executed Care Coordination environment, workflow and integration happen something like this:

The Personal Physician is alerted (in their EMR or from nightly payer reports) that their ACO attributed patient had an ER admission last night for a given diagnosis.  The Personal Physician sees that this is a patient who hasn’t been in the office for 6 months and who previously was not part of the ACO contact with the payer.  However the patient is now part of an ACO relationship and now falls under their new enhanced Care Coordination program.  The physician instructs their staff to call the patient and set an appointment for the patient to visit the doctor within the next 3 days.  At the visit, the patient’s Personal Physician evaluates the patient, looks at the combined payer and EMR data and the associated analytics in their dashboard.  They decide that the patient needs to focus on several things and tells the patient that while checking out from the visit, they will need to set up an office visit with the doctor’s Care Coordinator.