Cordata recently held the first in a series of webinars bringing together leading voices in care coordination to discuss its application across the healthcare landscape. The discussion featured Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, along with Ellis “Mac” Knight, MD, MBA, senior vice president and chief medical officer of Coker Group and Kimberly Zukowski, LMSW, CCM, Director of Care Coordination at WellStar Health System.

Here are some of the highlights from the discussion, which you can view here.

On the definition of care coordination:

Daniels: “It’s the founding concept of hospital case management. From that environment, I find that care coordination is best defined by integrating the definitions and features from the AHRQ and the NQF – Care coordination is a deliberate, longitudinal, multidimensional process of advocating for patients as they journey through the care continuum to:

● Promote continuity of care as the patient navigates the system;

● Reduce excessive, wasteful, duplicate or questionable interventions;

● Promote safe, timely delivery of care;

● Encourage and facilitate communication between patients, families and care team members;

● Engage the physician and care team to ensure all understand the goals of hospitalization and the treatment plan;

● Offer alternative considerations when appropriate or when the plan does not reflect the patient’s or family’s preferences; and

● Influence care team members to aim for a timely transition.

Knight: “More recently, the concept of managing patient care is about managing the process around clinical conditions, and has been a way to look at the care process from a patient-centered approach, a best practice approach and a cost efficiency approach. By putting it all together, we can develop care processes that are producing high quality, low cost care in a much more patient-centered fashion.”

On best practices for arranging care coordination around clinical conditions:

Zukowski: “The vernacular can be confusing concerning the different people who are involved in a patient’s case. Efforts need to not only educate patients on their specific disease process, but also help them understand the people involved in their case to help manage what’s going on in the patient’s life. That’s why we leverage the hospitalist model for enhanced care coordination. They are the member of the care team who is closest to the patient and who can affect real change in the patient’s outcome. And the care coordinators/case managers have easy access to share information on patients such as barriers to care at discharge, severe social determinants in play, and others.”

Daniels: “What you need to do is, in my opinion, a total redesign of the care delivery process, whether you’re talking clinical care delivery, care coordination and patient education, wellness care – all of those represent well-entrenched care processes that were developed in a fee-for-service system and were looked at as profit centers. Now with the advent of value-based care delivery, they need to be looked at as cost centers and eliminate the steps that add cost but do not deliver any improvements in quality or outcomes. Effective care coordination should also include the concept of identifying ‘hot spotters’ to coordinate, as opposed to trying to coordinate an entire population of CHF patients or brain cancer patients.”

See this article for more on Dr. Jeff Brenner’s ‘hot spot’ concept.

On disease-based populations as cost centers for hospitals:

Knight: “Hospitals and health systems should concentrate on their disease-based cost centers and tease out the non value-add steps. This process improvement is the best foundation-building step toward being able to coordinate care efficiently and in a manner that will bolster the ability to meet the requirements of alternative payment models. For example, the CJR bundle covers the PCP referral, orthopedic services, anesthesia, pharmacy, post acute rehabilitation, home health – anything occurring outside of the tenants of the bundle contributes to margin losses. The care team (and its IT systems) must then monitor for things like medically unnecessary serial CBCs being ordered, or if the patient is staying on the census longer than necessary.”

On hospital guidelines and initiatives:

Daniels: “Pathways, physician practice profiles, unblinded data; all of that is needed, and it’s all a product of the kind of culture that emanates from the C-suite. If care coordination is a core competency of the organization, those kinds of tools and guidelines will become second nature.”

Zukowski: All of our patients are risk-stratified at admission, using the LACE tool – so that we know which patients are at the highest risk for readmission way before they are discharged. It is the simple red, yellow, green concept across our patient population that keeps everyone on the same page.”

All of our speakers said they preferred the use of “guidelines” for care teams, as opposed to the more rigid pathways or protocols. They also agreed that there can, and should, be deviation on a case-by-case basis. Guidelines are guides only and not a panacea. Consequently, if there is a deviation, the entire care team should be alerted immediately as a learning experience – good or bad. Discussing these occurrences later as part of utilization review is good, but doing so in-the-moment provides for a better learning environment.

For those of you who missed our Care Coordination Leadership roundtable, please feel free to view it here.