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The Importance of Patient Care Coordination for Outcomes

Given the multiple tracks that healthcare can take, from inpatient to outpatient and even to community settings, there is a need for care coordination and management of the transition between providers and all settings of care. Unfortunately, this coordination is often episodic or overlooked, and it tends to be organized around a specialty, not primary care. Further, transitions frequently occur with no point person held accountable for coordination.

According to the Agency for Healthcare Research and Quality (AHRQ), “Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. The main goal of care coordination is to meet patients' needs and preferences in the delivery of high-quality, high-value health care. This means that the patient's needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care.”

Care coordination has been identified as an important way to improve how the healthcare system works for patients, especially in terms of improved efficiency and safety. Most importantly, care coordination applied in a targeted way has the potential for improved outcomes for patients, providers, and payers.

Some Examples of Care Coordination

Coordinated care is being implemented throughout the care continuum. You may ask, ‘What does a patient care coordinator do?” Here are some detting-specific examples from the New England Journal of Medicine of patient care coordination and how it can strengthen care:

  1. Primary Care Coordination – some organizations may use a ‘guided primary care’ approach in which an RN has primary responsibility for patients with multiple chronic healthcare conditions. The nurse coordinates with the primary care provider and any specialty providers to ensure that nothing is missed. Not only does this support better adherence to the plan of care, but it can reduce the overall cost of care.
  2. Acute Care Coordination – Handling patients after an emergency has passed and hospital discharge has occurred, acute care coordinators oversee the transition of care, from follow-up visits and prescriptions’ being filled to confirming additional patient instructions. This can impact readmissions and reduce mortality.
  3. Post-Acute/Long-Term Care Coordination – When patients are also residents in a nursing facility, transitions between levels of care involve changes in medication and care plans. Inadequate care transitions are a big risk for this population. Care coordinators in this setting wirk with patients and their caregivers to ensure every understands the care plan, has proper expectations, and advocates for maintaining the best patient quality of life possible.

How Care Coordination Can Impact Patient Outcomes

It’s easy to understand why care coordination could make a big different in how one interests with the healthcare system. Here are a few examples that demonstrate the potential impact:

  • ELIMINATE DISJOINTED CARE: Even within a healthcare entity, systems can be disjointed. It is common for processes to vary, sometimes widely, among different areas of an organization, and especially between primary care and specialty sites. Care coordination can smooth out these differences and make the experience feel more like a continuum.
  • PROVIDE REFERRAL CLARITY: Patients may attend an appointment and still be unclear about why they were referred from their primary care provider to a specialist. Care coordination can help with the process of making appointments, as well as with the vital step of what to do after seeing a specialist.
  • LIAISON BETWEEN PRIMARY CARE AND SPECIALIST: Both sides of a specialist referral process may encounter problems with the interaction—Specialists should receive clear reasons for the referral as well as adequate information on any diagnostic tests that have already been done. Primary care physicians need to receive all relevant information about what happened in a referral visit in order to respond and make adjustments to ongoing treatment plans.
  • PREVENT INFORMATION LOSS: Because referral staff deal with many different processes and providers, it is common for essential information to be loss. Care coordination helps prevent snafus involving lost records, ensuring that means care is as efficient as possible.

Through Care Coordination Nurses Are Changing the Culture

A previous HealthStream blog post about patient care coordination shared that nurses can change this culture of single-setting handoff by communicating: “Yes, you’re here today, but my colleagues have given me a better picture of where you are in your transition. Because of our time together and my commitment to your care coordination and managing your transition, I now have a better appreciation of where you’re going and who’s going to be taking care of you there.” Under the old paradigm, the message might have been, “This completes your visit today, and thanks for coming. Goodbye.” We now emphasize that the registered nurse is now invested in what’s happening to that person when they’re out of sight. This represents a major change in the way we think about how we provide care.

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