Linell Catalan

20 Mar, 2019
Follow Coleman!

Linell Catalan

20 Mar, 2019
Follow Coleman!

Care Coordination: Managing your Population

Successful care coordination is deliberate; it requires the organization and streamlining of patient care activities across the spectrum. Having well developed and skilled care coordinators is an essential part of any successful care coordination program. Equally as important is an organizational foundation upon which to support overall care coordination activities promoting the expansion of care coordination efforts and activities to the rest of the care team. Expanding the care coordination activities to the team creates opportunities for collaboration and decreases the likelihood of the patient falling through the cracks.

The NCQA, the National Committee for Quality Assurance has a Patient Centered Medical Home (PCMH) standard relating to care transitions, referral tracking, and follow up. To meet this standard, you must be able to track referrals until the consultant or specialist’s report is available and received. You must also have a system that enables you to follow up on overdue notes, results, or reports from those specialists or consultants. The care management system and the Patient Care Team play a crucial role in the success of this standard.

Strategic review of system functionality will help support and improve your care coordination program. Some key organizational approaches to promoting population health and quality of care through care coordination include: appropriate and proactive care, referral management, data utilization, and continuous system and progress review.

Creating systems to ensure that you meet the main needs of the patient will promote delivery services that are of high quality and value. A simple way to ensure you are meeting the needs of your patient is to develop access that meets those needs. Our Simplified Patient Scheduling (SPS) methodology is the foundation of this concept. Patients want to be seen by their Primary Care Team, but scheduling procedures in our offices often prevent patients from being seen when they want to be seen. In turn, they elect to present to the nearest Urgent Care (UC) or Emergency Department (ED). By providing patients with access to primary care at times that are convenient to them, you can reduce unnecessary ED and UC visits (which will reduce costs and eliminate unnecessary labs and imaging), promote continuity of care (which will increase quality), and improve the patient experience.

Ineffective transitions of care after admission can result in adverse patient outcomes, high rates of readmission, and preventable ED visits. In 2011, $15 billion in health care spending was attributed to CMS (Centers for Medicare and Medicaid Services) beneficiary readmissions within a 30-day period from the previous hospital discharge. CMS reports that 10% of patients returned to the hospital for readmission within 30 days of discharge. Studies show that discharge transitions are quite fragmented, with PCPs reporting the following statistics:

The good news? You can change these outcomes! In order to redesign the way your patient transitions. and to prevent these unnecessary costs and poor patient outcomes, you must evaluate your current practices and reconsider how you coordinate the care of recently discharged patients.

A study by the AHRQ (Agency for Healthcare Research and Quality) shows that nearly 20% of patients will experience an adverse event or outcome within three weeks of a hospital discharge. What’s worse, 75% of these events are preventable. When redesigning your post-discharge care coordination activities, you must consider the primary factors that are causing patients to have adverse outcomes, be readmitted, or end up in the Emergency Department shortly after discharge. These include:

  • Faulty communications between facilities and providers
  • Unclear or misunderstood discharge instructions (language barriers, reading level, etc.)
  • Untimely follow up and patient’s inability to follow through with recommended discharge activities
  • Incomplete or incorrect discharge instructions
  • Inability of the patient to perform discharge activities (to pay for medications, arrange transportation to referrals/specialists/etc.)

Please see our sample script for readmission reduction for guidance in completing this work.

Another concept that is crucial to ensuring that you meet the needs of the patient is making care delivery intentional and proactive. So much of what we currently do in health care is reactive; your patient needs become urgent because of a failure in the system that has historically relied on volume to support operations. The role of care coordination is following up, tracking, and guiding ALL patient activities. As we move toward value based care, prevention and proactive patient care activity will become the center of a system based health care approach, a system that is built around the needs of the patient.

But what exactly is proactive care and how do you make it happen? By expanding upon the efficiencies your team has built through implementing our team dance steps, you can create systems to promote care that are not only effective, but targeted and proactive. Don’t wait for your chronic disease patients to have a flare, or for referrals to go months overdue, or for your high-risk patients to end up in the Emergency Department; create an intentional system to track patient care.

Registries are a helpful tool in proactive patient care activity and tracking. A registry is a tool that is used to collect and manage a small subset of patient information. Commonly, registries are used to create systematic tracking of patient contact and follow-up needs; some advanced electronic health records (EHR) systems can serve the same function. When used effectively, registries allow you to monitor patient follow-up, examine gaps in care and testing, assist with pre-visit planning, and drive proactive health management and preventative care.

Another essential component to a well-run care coordination program is the referral management system.  Often times, patients receive referrals from a variety of facilities or providers. Inefficient or ineffective referral management programs can lead to patient frustration, contribute to poor patient outcomes, and result in duplication and waste for your staff. As the patient’s ‘home base,’ the Primary Care office is accountable for ensuring timely and accurate completion of referrals and developing a system that can accurately track and manage referrals. However, according to Kripilani (2007), Primary Care Providers (PCPs) only receive information back on a referral 37% of the time. Designing a referral process that is proactive and strategic can result in better patient outcomes by reducing barriers to care and improving the patient care experience. Components of a high-performing referral management system include:

  • Taking accountability for referrals from beginning to end. Tracking the referral from order through to notes being received back by the Primary Care Provider.
  • Developing connections within your care community and providers that you refer to on a regular basis or facilities that you receive referrals from on a regular basis.
  • Support patients throughout the referral process; make sure that they get the information that they need and that they understand that information.

To learn more about how to create a streamlined and effective referral tracking system, via our online training platform Referral Management Training and Tools.

A core function of the PCMH model of care, care coordination is a critical component to effective care delivery and quality patient outcomes. The development of an efficient and effective care coordination program requires multiple key transformations within a practice. Reducing fragmentation of care and making progress within a care coordination program will require that each practice decides how to implement changes based on its context and organization structure. For more information or assistance in fitting care coordination services into your model of care, please contact us.


U.S. Centers for Medicare and Medicaid Services, 2016. Hospital Wide (All Condition) 30-Day Risk-Standardized Readmission Measure.

Kripalani S ; LeFevre F ; Phillips CO; et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007; 297: 831-841

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