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Delivering Successful Care Coordination: Creating the IT Foundation for Accountable Care

September 25, 2013
by Joseph M. Taylor, with interview by Mark Hagland
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Joseph M. Taylor of FluidEdge Consulting offers in-depth perspectives on ACO development

Joseph M. Taylor is 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 this first section, Taylor addresses the topic, “The key elements needed to identify and stratify patient populations.” In the next couple of weeks, additional sections will address “The office and patient workflow, including integrating the role of care coordinators”;  “The expanded collaborative role among different members of the broader care team”;  “Tools to empower the care coordinator and track patient progress between visits”;  and “Reporting the outcomes needed to demonstrate success.”

HCI Editor-in-Chief Mark Hagland interviewed Taylor recently regarding this important article, and some of the overall strategic implications involved in laying the strategic and strategic IT foundations for accountable care organizations. Below are excerpts from that interview, followed by the first section of the article itself.

What made you decide to write this article?

What I was trying to get at here was trying to put into words a lot of the concepts and the things we’re talking to our ACO clients about, in terms of how to put together a successful care coordination program, in order to achieve ACO success.

Joseph M. Taylor

One of the challenges in ACO development is that the people, processes, and technology seem to be organized differently in every patient care organization, correct?

Yes. And there are four critical success factors here. The first is to incorporate, which means data integration. The second one is understanding, which is analytics and actionable information. The third one is act, which is care management, which is care coordination, and related activities. And the fourth is report, which is being able to demonstrate results. So the paper really goes into that. There are a couple of bullets focused on the workflow, the care coordination, the care team, and how to empower processes with tools. But really, I’m focusing on those four themes, with a little bit of extra detail on the “care” part.

We’re so early in the process of ACO development that it reminds me of the early history of the car, when no one knew how to drive, and there were terrible car crashes all the time. It feels as though everyone’s trying to invent fire at the same time here, in some ways.

Exactly. And you can perform these tasks in different sequences.

In the four areas you mentioned above, where are people and organizations the weakest, in general?

Lots of people have data, but they don’t always have it integrated, and can’t always turn it into actionable information. And in care management, they have a lot of talented people, but don’t have their organizations architected to support care management, or the tools needed to execute it. And in terms of documentation, even if you’re doing all the right stuff, will someone pay you for it, if you can’t document it correctly? Those are where the pain points are.

What is the core of your advice, as organizations begin to move forward in this area?

I think it’s really to plan. I think President Lincoln said something like, if I have six hours to cut down a tree, I’ll spend four hours sharpening my ax. So, put in the right plan, make it pragmatic, and deliver results and success measures along the way, so you’re not spending three years building something out. Build things incrementally, and document success along the way, and support your teams on the care delivery side and on the administrative side.

In other words, don’t try to boil the ocean?




Delivering Successful Care Coordination

By Joseph M. Taylor, FluidEdge Consulting

Care Coordination is not a new concept; however, it is being reinvented to meet the increasing demands of healthcare today. Personal physician driven, nurse executed, Care Coordination models will continue to evolve. It is the main intersection between informed care management and patient engagement within today’s new alternative payment models.  The new reimbursement models place increasing financial risk (and gain) directly on those for whom the patient is “attributed”.  Real world success or failure for Accountable Care Organizations (ACO’s), Patient Centered Medical Homes (PCMH’s) and physician-driven chronic condition and case management lies in the ability of their Care Coordinator’s to collaborate with the rest of the team and their understanding of the complexities and their relationship with their patients.

To go in-depth on the entire ecosystem of successful care coordination would entail writing volumes so let’s fast forward to the state we are in today in US Healthcare.  In doing so, I will focus on five (5) key areas over the next few weeks:

> The key elements needed to identify and stratify patient populations

> The office and patient workflow, including integrating the role of Care Coordinators

> The expanded collaboration role between different members of the broader care team


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