Linell Catalan

15 Nov, 2018
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Linell Catalan

15 Nov, 2018
Follow Coleman!

Care Coordination: An Introduction

It may be no surprise to read that the lack of coordination of systems throughout our current healthcare delivery model is frustrating and costly. While there are competing explanations for the inefficiencies that exist within it, The American Journal of Managed Care (2015) published a study[1] concluding that fragmented care is the primary explanation, and is associated with substandard quality of care, poor healthcare outcomes and a higher incidence of preventable ED visits and hospitalizations for chronically ill individuals. (Frandsen et al. 2015)

There are aspects of the following story that may sound all too familiar:

Mr. F is a 42-year-old homeless male. He is admitted to the hospital in March after walking into the emergency department (ED) with tightness in his chest, severe wheezing and severe shortness of breath. He is diagnosed with chronic obstructive pulmonary disorder (COPD) exacerbation and acute congestive heart failure (CHF). He has been homeless for more than a decade, his young heart made sick from smoking, prolific polysubstance abuse, psychological stressors and exposure.

Mr. F’s hospital stay is no longer than 48 hours. His condition is deemed stable, and he is discharged onto the streets instead of transitional care. His social worker gives him some paperwork, including listings of food pantries and shelters, and strongly encourages Mr. F to follow up with his primary care provider (PCP) within three to five days. Mr. F leaves the hospital with a month’s worth of medications and an overall impression that his health is on the mend. He thinks his dominant problem is that he “has bad lungs,” leading him to believe that it is all just a very bad case of asthma.

A couple of weeks after being discharged from the hospital, Mr. F meets Sheila, a case manager who works at a community wellness center focused on providing services to people experiencing homelessness. Sheila helps Mr. F find a clinic by calling his insurance company to find out what clinic he was assigned to.  Since she does not have medical background or training and isn’t aware of Mr. F’s medical history or recent hospitalization, she makes an appointment the first week of May to establish Mr. F as a patient.

At the end of April, a week before his medical appointment, Mr. F notices he is having trouble breathing normally. Since he had been discharged from the hospital four and a half weeks ago, he is out of medications. He decides to borrow a friend’s inhaler. It provides no relief, but believing he has asthma, Mr. F continues to use it. Within a couple of days, Mr. F’s condition worsens. He is coughing a lot and his heart is beating very fast.  Mr. F notices that the yellow stuff that he has been coughing up is now more pink than yellow and his chest is hurting a lot. Even though he is feeling tired and dizzy, he manages to check himself into a different ED across town.

Since Mr. F’s chief complaint is chest pain, he is placed in a room right away. Mr. F’s breathing and chest pain does not improve. Stat labs are drawn and he is placed on a heart monitor and given oxygen.  He is then whisked away to various diagnostic imaging tests. Within an hour of Mr. F walking into the ED, doctors tell Mr. F that he has a pulmonary embolism and needs to be admitted.

This time, he stays at the hospital for seven days.

Unfortunately, the tremendous weight of our disjointed systems is felt the most by  patients who are vulnerable to an incremental decline in their health. Not only are these individuals the least poised to navigate a fragmented care system on their own; oversights such as missing (or incomplete) referrals, as well as decentralized communication between insurance companies, labs, diagnostic imaging centers, specialists, and referring providers all feed an endless cycle that inevitably makes our patients sicker and health care more expensive.  In Mr. F’s case, his second hospitalization may have been prevented if he were enrolled in a transition of care program between the nearby primary care clinic and the hospital. An amalgamated communication line between the hospital, the community center (where Sheila, the case manager, works), and a neighborhood clinic could have prevented Mr. F from waiting six weeks before his next follow-up appointment, and running out of medications in the process.

What is Care Coordination?

According to the Institute of Medicine’s (IOM) report titled Crossing the Quality Chasm: A New Health System for the 21st Century[2] (2001), care coordination (CC) is identified as playing a pivotal role in redesigning a framework for a more safe, effective, timely, efficient, team-based, equitable and patient-centered health care delivery model. Simply put, care coordination brings intent and targeted focus in meeting the patient’s health care needs, preferences and goals by virtue of a deliberate organization of the patient/caregiver and family with multidisciplinary teams and community stakeholders (i.e. hospitals and specialists). As the Agency for Healthcare Research and Quality[3] (AHRQ) describes it, care coordination is connecting the right people at the right time to the right information.

Care Coordination is Not Care Management

Care coordination and care management, though terms often used interchangeably, are different approaches in health care delivery. Care coordination is expansive, strategic and community-based. It is impacted by the unique health care needs and demographics of the patient population. It involves facilitating connection between the patient and stakeholders with emphasis on resource utilization and possible cost containment. Embedded within a multidisciplinary team[4], care coordinators proactively maintain communication with patients (even when they are healthy) and strategically engage with patients who are at higher risk for worsening chronic conditions.

Care management, in contrast, is episodic. The model for care management typically focuses on one chronically ill patient at a time, assisting with medication management, creating care plans, and working as liaisons between insurance companies, hospitals and the patient’s primary care provider.  See graphic below:

But Can It Be Done?

Care coordination places primary care at the hub of all activities congruent with patient care and is a vital component for Patient Centered Medical Homes (PCMH). This is certainly recognized by health plans and various nonprofits dedicated to improving the quality of healthcare. Some have provided incentives for those willing to participate.

In May 2015,  Mercy Health System[5], a large non-profit health system in Ohio, and one of the largest in the United States, piloted a CC program as a response to Medicaid/Medicare’s Bundled Payment for Care Improvement Initiative (BPCI).[6] Focusing on one campus of Mercy’s multihospital system, the pilot was designed to track and coordinate transitions between acute care and ambulatory care. A nurse was hired to be the care coordinator. Her first task would be to speak face to face with the patient prior to discharge. The nurse’s first in-person interaction with the patient has led to a 90% success rate of patients responding to the initial 24 hour post-discharge call. The subsequent tasks included following up with the patient to provide support and education as needed and reminding patients of upcoming appointments.  If a patient was discharged to a Skilled Nursing Facility (SNF), weekly conference calls were implemented to ensure the SNF was adhering to appropriate rehabilitative goals.  Mercy Health System’s proactive approach, along with the implementation of a system-wide data tracking system, saw results in nine months.  Hospital readmission rates decreased from 20% to just over 8% and length of stay in SNFs dropped in half: from 28 days to 16.4 days. Though the direct amount of savings in health care costs have yet to be determined, this CC program is being rolled out system-wide with the ultimate goal of “no patient falling through the cracks” (McKnight 2017).

Redesigning Healthcare is Possible

Given the political climate and widespread payment variations, there are many unknowns about health care and the direction it will take. It’s time to take a proactive approach in making it better.  Care coordination is not only the next step in the evolution of providing a higher quality of health care for our patients, but is also a prerequisite for impending payment reform and the shift from Fee for Service to a Value Based Payment (VBP)[7] system.

There are innumerable ways to begin a Care Coordination program, as each program or model should be designed to meet the needs of your patient population. The process of developing an in-depth, well-developed, perfectly strategized program will certainly be an overwhelming endeavor into the unknown; however, there are resources available to you begin:

Is your health center ready to incorporate a care coordinator? Before getting started, it’s important to evaluate your space, your team and your current health care delivery model. What would you need set yourself up for success? A sustainable CC program is possible with the right framework[8]. Readiness Assessment Tool

Are you an administrator or manager in your clinic? In the second article in this series, we will highlight unique challenges in creating a Care Coordination model that suits your population and provides helpful tools to help you move forward. Coming soon, Article “Care Coordination: Building A Foundation.



Frandsen, B. R., et al. (2015). Care Fragmentation, Quality, and Costs Among Chronically Ill    Patients.  American Journal of Managed Care.

Crossing The Quality Chasm: A New Health System for the 21st Century. (2001).

Agency for Healthcare Research and Quality.

McKnight, W. (2017). Mercy’s Health System’s Innovative Care Coordination Program Improves

Quality Outcomes. Industry Edge.—july/mercy-health-system-39-s-innovative-care-coordination-program-improves-quality-outcomes.pdf?sfvrsn=2

Centers for Medicare and Medicaid services.

Coleman Associates. Are You Ready for Redesign?

Coleman Associates.  Principles of Redesign, Part 1.

Coleman Associates. Performance Dashboard.

Coleman Associates. Overview of Value Based Payment Reform.

[1] Frandsen, B. R., et al. (2015). Care Fragmentation, Quality, and Costs Among Chronically Ill    Patients.  American Journal of Managed Care.

[2] Crossing The Quality Chasm: A New Health System for the 21st Century. (2001).

[3] Agency for Healthcare Research and Quality.

[4] Building Effective Care Teams: A Provider’s Perspective:

[5] McKnight, W. Mercy Health System’s Innovative Care Coordination Program Improves Quality Outcomes. 2017.—july/mercy-health-system-39-s-innovative-care-coordination-program-improves-quality-outcomes.pdf?sfvrsn=2

[6] Bundled Payment For Care Improvement Initiative (BPCI):

[7] Overview of Value Based Payment in Primary Care:

[8] Principles of Redesign:


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