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

October 14, 2013
by Joseph M. Taylor
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Part three of a five-part series on creating the IT foundation for accountable care addresses “The expanded collaboration role between different members of the broader care team”

In part three of a five-part series on creating the IT foundation for accountable care, Joseph M. Taylor, vice president and ACO practice leader at the Wayne, Pa.-based FluidEdge Consulting firm, addresses the topic of “The expanded collaboration role between different members of the broader care team.” Parts one and two addressed the topics of “The key elements needed to identify and stratify patient populations,” and “The office and patient workflow, including integrating the role of care coordinators.”


Joseph M. Taylor

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

The success of accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) will depend upon physicians who embrace the concept of managing care across the care continuum and leading teams of professionals committed to evidence-based medicine while delivering on continuous quality improvement.

Today, much of the “coordination” conversation is around who is or who should be the “quarterback” on behalf of the patient / member.  Is it “Friendly Insurance Company’s” Case Manager, Condition Management Nurse, Inpatient Review Nurse, and/or Discharge Planning Nurse?  It is the PCP, their Care Coordinator, one of several specialists the patient is using or one of their nurses?  Keeping with the football motif, one thing is for sure, the patient feels like the football.  They are handed off, thrown downfield, punted and sometimes fumbled.   

The Stanford University-UCSF Evidence-Based Practice Center defines care coordination as "the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care."1   

In the ACO and Personal Physician driven, nurse executed, Care Coordination world, the above definition is so important and truly underscores the role of the Care Coordinator who needs to be:

  • Truly involved in the patient’s care, they work hand in hand with their patients
  • A facilitator of the appropriate delivery of health care services regardless of who “delivers” the service.  This includes all the care management activities in the walls of the insurance company, specialist care and hospital services. 
  • The one who marshals (with the Personal Physician) the personnel and other resources needed to carry out all required patient care activities. 
  • Informed of and relaying all the necessary information exchanged among participants responsible for different aspects of care. 

In short, they need to leverage their role as “trusted source” to help facilitate delivery of “the right care, at the right time, at the right place and for the right cost” – a promise I heard over 25 years ago when I started in this industry.  As I look back, and perhaps age myself, this seems like rural healthcare or Dr. Marcus Welby reborn.  Except this time it is enabled by technology, supported by a Care Coordinator, contains aligned financial incentives, and is focused on the total quality of care provided and improving measurable outcomes. 

Clearly, for patients with multiple conditions and providers, each member of the team tends to have specific, limited interactions with their patient.  In addition, depending on the team member's area of expertise, they also have a somewhat different view of the patient causing the health care team's view of the patient to become fragmented into disconnected facts and clusters of symptoms.  To be pragmatic, there are several obstacles that need to be overcome in this coordinated world.  Just to name a few:

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