Facing the Care Coordination Challenge

This article appears in the February 2012 issue of HealthLeaders magazine.

When it comes to clinical quality improvement, CEOs see care coordination as their greatest strategic challenge. In fact, with 10 possible answers, it was the choice of 30% of the CEOs who took the annual HealthLeaders Media Industry Survey. For perspective, improving patient experience, including patient flow, was the top strategic challenge for only 17%, the next most popular choice. How to overcome the care coordination challenge?

According to William Jacobsen, CEO of 37-bed Carilion Franklin Memorial Hospital in Rocky Mount, VA, and a vice president in the Carilion Clinic system based in Roanoke, VA, what's needed is "an army of care coordinators."

"Carilion has taken a stance to work toward coordination of care in a system that has the primary care physician as captain of the ship," he says. "But you just can't take your typical primary care physician and ask them to coordinate these people."

Jacobsen sees care coordinators as the glue that binds physicians, nurses, hospitals, rehabilitation centers, skilled nursing centers, and nursing homes, among others, around the needs of single patients. Currently, most care is still episodic, and information gained or treatments given at one location may not be known by others who treat the patient. Patients with multiple diagnoses are unquestionably some of the most expensive, so it stands to reason that someone who can tie the disparate sources of care together can improve quality and reduce waste, the two top goals of health reform.

"At the Carilion Clinic, we're focusing on managing chronic care because that's where we see the greatest need and the opportunity to reduce costs," he says. "But there's a behavioral aspect to it. We see care coordinators not only coordinating the clinical work, but just helping patients manage their life."
Count Jacobsen among the CEOs who consider care coordination at their organization as a "work in progress." Some 59% of CEOs, however, say care coordination is strong or very strong in their organization.

"I'm really surprised at that figure," Jacobsen says. "For us, the infrastructure is there to make it strong, but we have more work to do because so much of this depends on labor supply in the case of physicians and care coordinators."

Of course, there is an acute shortage of both competencies in the healthcare marketplace.

Apparently, there's also a shortage of physicians who are interested in senior leadership, as 36% of CEOs who responded to the survey have zero physicians in their senior leadership structure. That number would likely be even higher if respondents from physician practices (26% of the CEOs) were excluded from the results. Jacobsen says organizations that fail to place physicians in the top level of the management hierarchy are missing a critical piece of their strategy to improve care and cut waste.

"So much of this work is based on clinical decision-making and evaluating evidence-based medicine protocols," he says. "The model we use where physician leaders, surrounded by administrators, are driving the process is a good model. It's not the only model, but physicians need to lead the clinical decision-making, supported by the administrators and financial people to ensure clinical decisions are sustainable."

Some 45% of CEOs, however, report between 1% and 20% of their senior leadership team is composed of physicians.

Some 54% of CEO respondents say they will fuel growth through outpatient strategies—the most popular answer, followed by starting or increasing promising business lines or facilities, at 49%. Jacobsen suggests that hospitals are beginning to realize that any one strategy is not the best way to fuel long-term growth.

"We are seeing some chipping away at profitability on the outpatient side, but the bigger point is that the future is in looking at the entire system holistically, not just the silos," he says. "We're looking at the entire experience for the patient as opposed to searching for short-term gain."

Another interesting response to the survey revealed that 60% of CEOs said healthcare can't solve its own problems because of "too much self-interest among the different stakeholders."

This response could mean that healthcare CEOs feel they are not in control of what they're being asked to do, and that other industry sectors, from payers to government, aren't really interested in working with them to improve care quality—they just want lower costs.

Jacobsen prefers to look at the challenge from a more positive perspective.

"Events happen which lead to an outcome. Your response is your only variable in that equation," he says. "We've got to be a part of the solution, and the government can't do that for us—they don't know enough."

Finally, among other interesting data, 60% of CEOs thought that quality would improve by increasing the scope of care of nurses within their organizations. Typically, physicians are seen as resisters to this type of change, but Jacobsen says that is going away as physician shortages bite into productivity.

"Advance practice nurses do an awesome job and we need more," he says. "The U.S. is opening new medical schools, but we still don't expect to produce enough physicians to meet our needs."

Jacobsen argues that much of the problems that bedevil senior executives hinge on better population health, which requires much more intensive work with the patient on variables that lie far outside clinical challenges. Hospitals aren't used to responsibility for such work, but they recognize the need to become more proficient.

"I had a Medicaid patient last year who used my ED 66 times," Jacobsen laments. "What we're dealing with here is that this person is disabled, and there's huge access issues around other sites of care. If they had access to the behavioral health they needed, transportation, and primary care, they would not do this."

This article appears in the February 2012 issue of HealthLeaders magazine.