Clinical care coordination is a process that benefits patients and their families, healthcare providers, payer organizations, and population health efforts as a whole. The practice offers increased options for managing patients faced with a high-risk, high-cost diagnosis, comorbidities, or those transitioning between facilities or to their home. The efforts facilitate proactive management of patients to remain engaged in their health and improve communication with their caregivers. Care coordination is optimal for a patient’s wellbeing, their continuity of care under their providers, and when they undergo a form of transition.
Improving a Patient’s Long-Term Health
The Agency for Healthcare Research and Quality states that “[c]are coordination is any activity that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time.” While frequently incorporated by providers into the care of older, higher-need populations, care coordination can also help those in good health. As care coordination’s function is to bridge any gaps and remain proactive with a patient’s health, it can help with critical tasks like identifying those in need of recommended screenings to close care gaps. Care coordination also promotes medical access for patients. When they have advocacy in care providers who serve as a point of contact, creating personalized care plans based on their needs and ensuring they are following the steps, patients remain engaged in their treatment.
Improving Providers’ Delivery of Care
Care coordination promotes cooperation and information-sharing between multiple providers and specialists serving a patient, reducing fragmentation throughout care. An example of “fragmented” care is one provider may not know of a service another provider performed already for the patient or duplicated it in their care plan.
Providers that coordinate care for patients can identify their needs before appointments, allowing them to make the most of limited face-to-face or virtual time. Coordinators also help determine where a patient should next seek care at the sign of a change and plan for it by equipping the next practitioner with their records and responsibilities. Care coordinators have an in-depth insight into a patient’s social determinants of health (SDoH) and can help address potential barriers interfering with their appointments, medications, or other plan steps. Above all, care coordination helps patients approach their care the way they want, even with end of life planning.
Improving Care Transitions
In the coordination of patients with high-risk conditions or comorbidities, there are bound to be multiple transitions over their course of care. Whether that is a change in facility, a change in provider or personnel, acquiring another specialist, or transitioning to care in the home, care coordination promotes an easy transfer process. Patients also undergo different physical levels of change in their life and in their care journey over time that warrant a change. One of their conditions may have developed further, or they had an episode that requires different oversight. Transitions can also occur simply as a result of new needs as they age. With detailed documentation, care coordination improves patients’ transition to the location or care provider of their choosing.
A Worthwhile Investment
Care coordination, when performed well, benefits patients, providers, and payer organizations. Patients receive optimal care, providers are better informed, and there is less wasteful spending on things like unnecessary testing or duplicative procedures. The level of organization allows for a vendor like Lightbeam to compile a detailed analysis of a client’s high-risk population, break it down further into smaller cohorts, and direct targeted care management interventions. Care coordination is another level of invaluable visibility that is a worthwhile investment in care management.
Christine DiNoia, BSN, RN, is the Director of Clinical Programs at Lightbeam.