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

November 5, 2013
by Joseph M. Taylor
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Part five of a five-part series addresses the topic, “Reporting the outcomes needed to demonstrate success”

In part five of a five-part series on creating the IT foundation for accountable care, Joseph M. Taylor of the FluidEdge consulting firm addresses the topic, “Reporting the outcomes needed to demonstrate success.”

In the previous three parts of the series, Taylor addressed the topics “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”; and “Tools to empower the Care Coordinator and track patient progress between visits.”

Reporting the outcomes needed to demonstrate success

There is an old question, “If a tree falls in a forest and no one is around to hear it, does it make a sound?"  It gets to the question, “Can something exist without being perceived?”  The same question can be asked by those who pay for care management activities.  If,

  • The entire care team does amazing work with their entire attributed patient population
  • All the meaningful gaps are closed
  • The medication list is optimized and adherence is at 100%
  • Hospital re-readmission rates drop significantly
  • Inappropriate ER use is down
  • Site of service is optimized
  • Your personal physician lead care coordinator is extremely effective

…and you can’t report or demonstrate the results of your activities; does it really matter to the likes of CMS and your commercial payer contract holders when it comes time to pay you for your efforts?

There are many definitions of “value” that have been documented. When setting up reporting systems look to be able to demonstrate the following: Value= Clinical Outcomes + Patient Experience (Price x Utilization)


There seems to be an endless supply of measures and organizations who govern them.  Meaningful Use, HEDIS, PQRS, ACO, Stars, Risk Adjusters, CAHPS, the list goes on and on.  To document effectiveness is to be considered effective.  To not be able to demonstrate effectiveness systematically though these measures means you have a long way to go in the minds of those who contract with you.  

Going back to the beginning, a well-defined data integration strategy and execution is the key.  If the information is not brought in, it can’t possibly be reported out.  Taking in all the disparate data sources, defining them, analyzing the data and turning it into meaningful information, and using it to direct potential care opportunities in a timely basis starts the process.  Collecting the data on all the clinical activities, results and outcomes is the next essential step.  Adding patient engagement data, remote monitoring device data and self-reported data help to round out the patient activity in between office visits.  Tying the data to the financial system and measures is critical as well to achieve a full 360° view into your program’s effectiveness. 

Successful care coordination is achievable.  While getting there is not easy, it is essential if we are to deliver on the goals of ACO’s and PCMH’s.  Failure to do so means higher cost, a worsening in the health status of the country and greater Federal Government involvement and “solutioning” to fix the issues we won’t fix on our own.


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