Intelligence Report: Care Coordination Considerations

Michael Zeis, September 2, 2015

As healthcare leaders recognize the importance of the care continuum, they need to rethink responsibility for care coordination.

This article appears in the July/August 2015 issue of HealthLeaders magazine.

Care coordination in the form of patient transfer is a relatively mature activity, at least in the acute care environment. But new attention to value-based care and at-risk reimbursements means that care coordination is poised for development and growth.

Just over two-thirds (68%) of healthcare leaders say their organization has a care transition function that supports patient transfers to or from hospitals, which is the setting with the highest percentage of supported transfers. Other settings cited range between 40% (for clinics or federally qualified health centers [FQHC]) and 55% (for home health agencies), which gives hospitals a clear but not commanding lead.


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Despite the growing expectation that primary care physicians should occupy pivotal spots in care coordination activity, primary care practices are in the middle of the group, with 53% of respondents saying their organization has a care transition function that supports patient transfers to and from primary care. "That means that half the people out there are being coordinated without [a primary care] physician's direct involvement," says Gaurov Dayal, MD, former president of healthcare delivery for St. Louis–based SSM Healthcare, which operates 19 hospitals, an insurance company, nursing homes, home care, hospice, telehealth, and a technology company.

Examining new roles

The presence of care transition activity is related to participation in narrow networks. Slightly more than one-third (35%) of respondents say their organization is in a narrow network, and 31% are not. For every one of eight care venues examined, higher percentages of those whose organizations participate in narrow networks than those that do not say their organization has a care transition function. The difference in care coordination activity between narrow network participants and nonparticipants is especially great for outpatient specialty care (64% vs. 41%), outpatient primary care (66% vs. 46%), and rehabilitation facilities (55% vs. 38%).

Although virtually all interactions between patients and providers can benefit from care coordination, providers tend to focus their efforts (and resources) on patients most in need. Survey results show that diabetes (68%) and heart failure (65%) are conditions for which providers most often currently (or expect to within three years) assign a part-time or full-time staff person to coordinate care. Diabetes and heart failure stand out—COPD is mentioned third most frequently, by 49%.

Michael Zeis

Michael Zeis is a research analyst for HealthLeaders Media.

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