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Care Coordination a Cost-Cutting Quality Driver

 |  By Alexandra Wilson Pecci  
   March 11, 2014

Part II of an in-depth conversation about care coordination with two nurse leaders delves into the reasons why hospitals are looking at care coordination and transitional care so intensively—quality, cost, and outcomes.

In part two of my conversation with two nurse leaders in care coordination, we talk about the care coordination that's happening in hospitals today; the challenges for patients, families, and providers; and how to bridge the gaps between the two. We're talking with:

The following is Part II of our conversation. Part I is here.


See Also: Care Coordination Tough to Define, Measure


HLM: How common now is comprehensive care coordination in hospitals and health systems?

Lamb: Increasingly so. There are a number of quality issues that have really pushed care coordination to the fore, particularly the concern about hospitalization and rehospitalization. So a lot of hospitals and health systems are really looking to integrated care coordination to assist them in reducing in reducing avoidable hospitalizations.

Probably the biggest area where we're seeing care coordination roles and processes being put into place is in transitional care. Care coordination is increasingly common, primarily in the area of transitional care, hospital-into-community setting.

I think we're seeing it more in the emerging health systems: In patient-centered medical homes and in accountable care organizations, primarily because there is a great deal of focus on making sure that services are used effectively and efficiently and quality outcomes are achieved through coordination and team work.

So we're seeing a growth in care coordination across the board… but increasingly so in new delivery systems that really are predicated on better integration, better coordination of care, and using primary care as a hub, so you're seeing more care coordination in primary care delivery systems.

New Payment Models; Better Coordination

HLM: What's missing still?

Lamb: I don't know that any part of the care continuum is being left out that this point. Some parts are newer players than others. So the hospitals really are looking at care coordination and transitional care intensively because of the link to quality and cost, outcomes, and incentive.

The newer players on the scene are the nursing homes, and there is a growth of care coordination models for nursing homes. Home health is coming into it, and as I mentioned before, the primary care settings really are looking at care coordination more in depth because of the new delivery models and the new payment models.

HLM: What are some of the challenges of care coordination for patients and families?

Lamb: We have to step back on this and recognize that patients and families are probably doing the bulk of care coordination, and they are facing significant challenges in keeping services linked, in making sure information flows across providers, in getting the right service in the right place. This was really the impetus for me [to work on] the book on care coordination that the American Nurses Association published.

I've been working in this area for many, many years. When I started doing it for my own family members… it heightened my awareness of how difficult it is for family members to be able to get information consistently across providers, especially for family members with multiple chronic illnesses who may be very fragile and vulnerable.

I frequently ask audiences of healthcare professionals, nurses, physicians, therapists about their experiences coordinating care for their own family members: How many of you are doing this? And most commonly, three-quarters to almost all of the hands go up in the audience.

And then I'll ask them: How well is it going? How many of your feel that you're able to do it effectively? And almost every hand goes down. It's very difficult, as a family member, to make sure that all the pieces are coming together. [And to ensure that the right information is crossing all of the different lines between providers and settings in a timely way, accurately, consistently.

Some of the research in this area is absolutely fascinating about how much time family members are spending doing this. It's very significant. We're talking upwards of six, to ten, to 20 hours a week. When I was doing this for my mother, I was doing it constantly, and I was coordinating it across 2,000 miles… very hard work, very frustrating, and often very frightening for family members.

Better Coordination Linked to Reduced Admissions

HLM: What is the bridge then between what families are doing already with a lot of frustration and what is being done on the provider side? And what can be done on the provider side?

Lamb: That's a great question. The bridge is really the individuals who are taking accountability [and] responsibility for making sure that those connects happen. Most commonly that's going to be nurses in the hospitals and primary care settings in home health, as well as often social workers maybe doing care coordination, [and also] primary care physicians.

But those individuals really are the bridge. Those are the people who are asking [patients] the critical questions [such as], "What are your preferences what is it that is a priority in your life? What do you want to have happen? Who else is involved in your care? What's going on?"

And that's where the plan of care becomes really important. I see it as a significant stride that we are moving towards one plan of care for each patient, which really encourages all providers to work from the same page. Going back to your earlier question of what's working, we have some very effective models in transitional care.

You're probably familiar with Mary Naylor's model from the University of Pennsylvania…there's also Eric Coleman's model. And the data supporting their effectiveness in terms of reduced admissions, patient satisfaction, [and] quality of care outcomes is very promising.

It's some of the new areas that we were talking about that are just beginning to emerge now in terms of nursing homes, home care, [and] primary care. I think that what Maureen was saying before about the new ambulatory care measures is really important and exciting because that begins to bring in primary care as a hub of all this work.

Dailey: ANA's book that Gerri was the editor and author of [illustrates that] there are some very effective roles in which nurses and other providers are providing care coordination, such as the nurse navigator role. [It also discusses] what… it takes for nurses or other providers to be successful in those roles.

ANA has a center for Nursing Practice and Work Environment [that can guide the development of the] workforce as well as the preparation for the role and [identifying] the work environment that is conducive [for] nurses [to] excel in care coordination within settings across settings, and specific roles for patient populations that are at high risk, such those with multiple chronic conditions.

I'm glad Gerri mentioned that because with the potential care coordination codes for added reimbursement for eligible providers, that's exactly the population that the Centers for Medicare & Medicaid services is looking toward.

How can we do a better job for those at-risk, frail populations such as the geriatric populations or those with multiple chronic conditions? What are the effective models and roles that we can prepare the nations nurses and other providers to either participate in teams in care coordination or lead care coordination within the team?

Acknowledge and Measure It

HLM: What can nurse leaders take away from this conversation to improve care coordination in their own organizations?

Lamb: There's a number of things that nurse leaders, administrators, the folks that are leading care coordination can be doing. I think we can start with…recognizing how much care coordination nurses are doing every day. There's research that shows that in the hospital as well as in other settings nurses are spending a significant amount of time in communication, in coordination, in making sure that the right things are happening at the right time.

So one thing is to acknowledge that it's happening.

Two is to draw attention to the amount of care coordination that nurses are doing so that opportunities for improving it and bringing in new innovations in care coordination can be front and center. Certainly the whole discussion that we were having about measurement [is important.] There's a lot going on in terms of developing new measures that really capture the work of care coordination effectively, and nurses and nurse leaders who have really supported the documentation and the capture of measurement for care coordination really should be applauded.

This is important work. The leaders have so much that they could be doing to support bedside nurses in doing this work, in improving it, in measuring it, and ultimately in making sure that patients get the benefits of it.

Dailey: I'd just add that yes, measurement is a tool to improve care coordination and we want the right set of measures. Not a proliferation of a lot of measures, but measures that are meaningful to the front-line commission and the teams and [that are] high-impact; that they actually can be used as one of the levers to improve outcomes.

The other thing I'd like to mention is that health information technology is a structure of care. Just like the right staffing and the right mix of clinicians on the team [is important, to too is] the right health information technology so that we can be efficient and effective.

Lamb: I'd like to go back and just make a plug for the importance of patient-centered measures and for nursing leaders to pay close attention to what's going on in this area. It's one thing to have measures of care coordination that seem pretty straightforward, like, When you leave the hospital do you have an appointment with your primary care provider? That's certainly important but it's not sufficient.

Care coordination really centers around what the patient's needs and preferences are, and making sure that they have access to those care and services that really are going to help them be successful in staying in the community, and being healthy, as well as having a good healthcare experience.

We're not going to do that with oversimplified measures that look at "Do you have an appointment?" or "Did you use an electronic health record for med reconciliation?" Those are important, but they're not enough that really gets at the core of all of the integration and the connections that are necessary to make care really well coordinated.

HLM: Is there anything else that you want readers to take away?

Lamb: A lot of the impetus for [the attention on care coordination] is the National Quality Strategy. But I think that it's important particularly, for nurses, to realize that care coordination is not new in healthcare or in nursing. Nurses and other health professionals have been working at this for almost half a century now, and so we have a lot of lessons, a lot of history, a lot of really outstanding work that is all coming to bear on improving care coordination right now.

So I guess another takeaway would be is to not only celebrate that path but use it effectively because there's just so much opportunity right now to make care coordination work better for patients and families, as well as the health system.

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Alexandra Wilson Pecci is an editor for HealthLeaders.

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