Taking the mystery out of care coordination management


Care coordination isn't new, but with value-based payment, patient-centered medical homes, accountable care organizations, and other alternate delivery and payment programs exploding around the country, it has moved into the forefront of many coffee klatch conversations as well as policy discussions. With the advent of the new care coordination management (CCM) code, many practices are working at putting systems and workflows in place so that they can provide the required services efficiently and bill appropriately.

A patient with at least 1 chronic disease typically sees several clinicians in several settings using several different record-keeping mechanisms. There are a primary care physician, 1 or more specialists, a lab, a pharmacy, possibly an imaging center, and a hospital or nursing home or surgery center. The only common thread is the patient. The insurance company probably knows about all these care settings but does not have enough information to serve as the connector. Care coordination means different things to different people, but the bottom line is that the care delivered by 1 or more clinicians to 1 patient is organized and appropriate so that the patient has optimal outcomes.

The Agency for Healthcare Research and Quality (AHRQ) recently published a Care Coordination Measures Atlas. While it may be tedious to slog through, it includes some tips to organize a practice that will facilitate care coordination. There are 9 “domains,” or broad areas of care, that practices can develop, or re-develop as the case may be, to facilitate and improve care coordination activities for their patients. All of these are good not just for care coordination but for the practice in many other ways as well.

Accountability is key. All members of the care team needs to know what their roles are, when to transfer responsibility, and how their parts relate to other parts. Good communication, which includes both interpersonal communication and transfer of information among entities, is the basis of good patient care. Interpersonal communication can be in person, on the telephone, or in writing by e-mail or good-old-fashioned letter between clinician and patient or clinician and other team members (caregivers, other clinicians, or facilities). But in today's world, the transfer of information (orally, electronically, or in writing) among various members of the care team is equally important. While the 2 may occur simultaneously, it is important to keep all types of communication in mind.

Facilitating transitions between settings (e.g., inpatient and outpatient, primary care and specialty) and as disease states or patients themselves change (e.g., episodes, completion of chemotherapy) is another aspect of care coordination. This may involve a close look at work flows involving timely treatment and/or communication to ensure that nothing is falling through the cracks. A needs assessment and creation of a plan of care help manage these and future needs for care coordination, including physical, emotional, and psychological health, functional status and the ability to self-manage, and treatment and support recommendations. There are many templates and tools that can help practices design a system to provide a jointly created proactive treatment, care, and support plan.

Any plan made requires monitoring, follow-up, and adaptation as needs change over time. Since no one has a crystal ball, things happen and sometimes the plan needs to be fine-tuned because of new information or circumstances or to correct any system failures. Patients need to be involved in their own care, so the practice needs to support self-management goals. Education and support of these goals should be adjusted to each patient's abilities and preferences or those of caregivers. Many community resources are available to support patient health and to meet self-management and treatment plan goals. For instance, support groups, social services, or programs such as Meals on Wheels can meet patient needs.

Finally, the practice should align resources with patient and population needs. At the population level, system-level approaches can address the needs of specific populations (such as community supports available to seniors or nutrition services for diabetics). At the patient level, the care team can determine which system-level supports are appropriate.

These activities, or “domains,” are all inter-related and may seem intuitive for good care management and care coordination. While some readers may believe that excelling in all of these domains requires a dedicated care or case manager, it may be a matter of organizing the care team so that care is delivered at the right time in the right place by the right people, but with one overarching “hub” care team member coordinating the care of each patient or patient group. Providing excellent care requires providing excellent care coordination, and that will go a long way toward preparing for value-based payment, becoming a patient-centered medical home, and succeeding in an accountable care organization.

To access AHRQ's new Care Coordination Measures Atlas, go online. For ACP's High Value Care Coordination Toolkit, go online. The ACP Practice Advisor® has many care coordination tools and templates that can be easily customized and implemented.