Care Coordination
Summary
Health care extends outside of a hospital's four walls. This topic area explores strategies hospitals are currently employing to improve care coordination. From reducing readmissions to improving care follow-up, these hospitals are focused on reducing costs while provide patient-and family-focused care to their communities. The end result is quality health care that meets the 6 IOM aims.
“Care coordination is an important aspect of healthcare that helps ensure that patients’ needs and preferences for services are understood and that they are shared as patients move from one healthcare setting to another or to home, as care is transferred from one healthcare organization to another or as care is shared between a primary care professional and specialists. Care must be well coordinated to avoid waste, conflicting plans of care, and over- under-, or misuse of prescribed medications, tests, and therapies.”
In today’s fragmented health care delivery system, hospitals are challenged to coordinate patient care that involves multiple providers and places. Persistent fragmentation as patients move from one setting to another contributes to gaps in quality and efficiency that adversely impacts their care.
Health care is currently delivered in episodes. Patients see several different physicians, or spend time in a hospital, followed by a nursing home or their home. Since few mechanisms allow the transfer of patient information from one care setting to another, continuity of care is often interrupted, resulting in re-hospitalizations, duplicative services, conflicting care recommendations, and a greater potential for error and patient harm. This results in a higher cost of care. [i]
Aligning incentives for providers and patients is paramount to move the current care delivery model to a patient-centered model in order to share accountability for the patient’s overall care. “Our payment system rewards volume and does not recognize value, and fails to compensate care coordination or the infrastructure necessary to support more coordinated care,” according to the Commonwealth Fund Commission on a High Performing Health System.
The AHA recently brought together a panel of clinical experts to help hospital leaders identify and begin to reduce re-hospitalizations. The panel identified several places to start including:
- Examining your hospital’s current rate of readmissions.
- Improving communications to those caring for the patient after discharge.
- Advocating for improvement in the community’s ability to tear down barriers to successful care transitions.
- Adopting interventions that may reduce readmissions.
Read the complete suggestions on “What Can Hospitals Do to Reduce Readmissions?”
Linkages to IOM Six Aims
Safe—67.1% of Medicare patients discharged with medical conditions and 51.5% of those discharged after a surgical procedure are rehospitalized or die within one year after discharge, according to a NEJM study.
Effective—19.6% of Medicare patients discharged from a hospital are rehospitalized within 30 days and 34% are re-hospitalized within 90 days. Further, 50% of patients who returned to the hospital within 30 days of undergoing treatment other than surgery apparently did not see a doctor before they were rehospitalized.
Efficient—The average hospital stay for rehospitalized Medicare patients is 13.2 % longer than the stay for patients not hospitalized within the previous six months.
Business Case
The New England Journal of Medicine study estimated the cost of unplanned hospital readmissions for Medicare patients was $17.4 billion in 2004, accounting for approximately 17 percent of total Medicare payments to hospitals.
Health Care Reform/Regulatory/Policy Considerations
The proposed FY 2010 federal budget targets the reduction of re-hospitalizations through a combination of financial incentives and penalties. The AHA is working to ensure hospital and community needs are reflected in health care reform.
Linkages to Performance Excellence
Perfect the Patient Experience — Providing patients and families with knowledge and tools aimed at improving their ability to self-manage their conditions has potential for reducing re-hospitalizations.
Manage organizational variability — Inability to transfer information between providers and care delivery settings results in lack of coordination and continuity for patients.
Resources & Tools for Care Coordination
[i] Care Transitions InterventionSM by Eric A. Coleman, MD (accessed on July 1, 2009)
