Better Care Coordination is a National Priority

Posted by Excerpt from Outside Publication

June 26, 2019 at 4:01 PM

See OncologyLive > Vol. 20/No. 12  for full article, Clinics Strive to Improve Revenue and Patient Care Amid a Growing "Cost Consciousness".

"Better care coordination has been identified by the Institute of Medicine (IOM) as one of multiple national priorities for action to improve the quality of healthcare.2 Care coordination can take many forms—follow-up on medication adherence, appointment monitoring, hiring of clinical coordinators, establishing after-hours portals, holding care team consultations—and oncologists have been working harder on these points, spurred in part by the OCM and CMS’ growing, incentive-based emphasis on value-based care. Many factors impair coordination and contribute to poor outcomes. These range from poor follow-up on testing to electronic health records that don’t synchronize with other digital platforms.3

Privately developed models of care that emphasize better coordination have also emerged. The oncology patient–centered medical home has been touted as being able to save million per physician per year. It can align systems and resources and thus reduce fragmentation, support shared decision making, and better control costs, according to chief architect John D. Sprandio, MD, chief of medical oncology and hematology at Consultants in Medical Oncology and Hematology and director of the cancer program at Delaware County Memorial Hospital, in Upper Darby, Pennsylvania.4

However, as with any transformative internal revamp, the model requires “nothing short of a substantial, disruptive, and coordinated response by the practice to reengineer the delivery of care,” as well as the creation of a sustainable business model that can be achieved only by actively engaging with payers in the development of new payment methodologies, according to Sprandio. Lighter measures are also available to achieve coordinated care.

One way is to hire nurse navigators, according to Mark Krasna, MD, who spoke on the subject at the ACCC’s 2018 annual meeting. Nurse navigators work with staffers and doctors at all levels in oncology practice and can help achieve consensus on an individual patient’s care, Krasna stated at the event. He added that care coordination reduces unnecessary x-rays and magnetic resonance imaging, among other tests, and puts practices in good stead with payers. He also noted that patient satisfaction is higher at facilities that work hard on aspects of care coordination. From a business perspective, these satisfied patients may help boost referrals by telling friends and family about their experience with the practice, Krasna noted.5

Care coordination cannot help but be beneficial for patients, Oyer added. A well-oiled system for patient referrals can add to the business benefits of coordination, which is helped along if oncologists pull out all the stops. “When you have a streamlined referral process, that is attractive to patients, and they are more likely to choose you to provide their care,” he said.

In a sense, care coordination is also workforce optimization, and that is good for running a business, Oyer said."

1Association of Community Cancer Centers 2018 survey finds multiple barriers to cancer program growth [news release]. Rockville, MD: Association of Community Cancer Centers; January 16, 2019. Accessed May 22, 2019.
2Initial national priorities for comparative effectiveness research. National Academies website. Published June 2009. Accessed May 22, 2019.
3Weaver SJ, Jacobsen PB. Cancer care coordination: opportunities for healthcare delivery research. Trans Behav Med. 2018;8(3):503-508. doi 10.1093/tbm/ibx079.
4Sprandio JD. Oncology patient-centered medical home. J Clin Oncol. 2012;8(35):47s-49s. doi: 10.1200/JOP.2012.000590.
5Cryts A. Improve care coordination in cancer care: 2 key focus areas. Managed Healthcare Executive. March 16, 2018. Accessed May 22, 2019.

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Costs of Readmissions are Up:  Have You Done Your Service Line Math?

Posted by Cam McClellan Teems

June 24, 2019 at 6:13 PM

The Centers for Medicare & Medicaid Services penalized half of U.S. hospitals for their readmission rates in 2016. The penalties are controversial, and major professional organizations such as the American Hospital Association, have questioned the methods used to assess the data.  Recently, the AHRQ examined readmission trends and costs using the 2010-16 Nationwide Readmissions Database.

Here is a small sample of a recent list that was published by AHRQ with average readmission costs and readmission rates for the top 2.  This includes patients 1 year and older, readmitted for any cause within 30 days of first admission:.

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Guest Blog: Still Using Fax Machines And Sitting On Hold When Scheduling Outbound Referrals For Patients? It Can Be A Nightmare - But It Does Not Have To Be

Posted by Guest Blogger

April 1, 2019 at 10:07 AM

Here is the situation.  Scheduling for patients with outside providers is often the hardest part of a navigator or care coordinators role. It is almost never immediate, takes multiple phone calls and compliance rates with the planned appointment is far from a given.  In fact, studies show that >40% of patients do not follow up with the referral appointments their doctor recommends. Why is that?

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SDoH Can Derail Your Carefully Constructed Care Plans

Posted by Cam McClellan Teems

January 10, 2019 at 9:52 AM

Consider, for a moment, some statistics[3]:

  • 28% of US adults report that they have at least two chronic conditions
  • 26% of US adults say that they had experienced emotional distress in the past year that was difficult to cope with alone.
  • US adults were more likely than adults in all other countries to report that they were “always” or “usually” worrying about having enough money to buy nutritious meals and to pay their rent or mortgage.

It is not just the complex disease profile and treatment plan. In fact, those well-crafted plans can be easily derailed if the conditions in the places where people live, learn, work, and play are contributing to stress and lack of an ability to heal.

Patient conditions are not only clinical. They might be a cancer patient living in a shelter and facing daily transportation issues to get to chemotherapy...or a recent overdose or behavioral health illness patient who needs hand-holding to elect treatment...or a low-income diabetes patient with unstable access to nutritious food. The list goes on doesn't it? The role of the Care Team is rooted in the disease. However, the disease requires a full understanding of the patient's personal situation & environment in order to truly care for them and talk to them in an impactful way. It is the only way to really help them, reduce costs, and improve the system.

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The 71%: Is Your Cardiovascular Continuum Flatlining?

Posted by Cam McClellan Teems

September 12, 2018 at 2:18 PM


Cardiovascular disease is the leading cause of hospitalization and mortality [1]. Every 40 seconds, one American will suffer a heart attack, which is among the top ten most expensive hospital principal discharge diagnoses.[2] And to add insult to injury, the The National Health and Nutrition Examination Survey (NHANES) showed that cardiovascular expenses have one of the largest portions of current spending—an amount estimated to triple over the next 20 years.  This means that the cardiovascular care continuum is an imperative for most providers, hospitals and health systems. 


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Topics: care coordination, cardiovascular continuum

Sorry….Wrong Number!

Posted by Gary Winzenread

July 26, 2018 at 9:34 AM

What can we learn from the Caresync story?

As an entrepreneur trying to innovate in the healthcare market, I have a soft spot in my heart for others taking on the challenges of changing what may be the most regulated, conservative, bureaucratic and risk averse market in the American economy. The point of this article is not to take any pleasure in the failure of another’s attempt at innovation in this tough space. In fact, I deeply respect the effort Caresync, and many others that met the same fate in this industry, have made to improve our health system by lowering costs. But the silver lining of any failure is the learning that it grants us, which has made me ask the question, What can we learn from the Caresync story?

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Topics: Financial Incentives, care coordination

The 71%: Gaining control of the care for your most expensive cancer patients

Posted by Cam McClellan Teems

June 25, 2018 at 4:05 PM


The Chronic Care Model (CCM) that emerged in the 1990s - was a model designed to retool primary care and implement critical components to proactively manage patients with chronic conditions[1]. However, the model could not keep pace with the sickening of our population (e.g cancer, heart disease, diabetes, addiction, etc). Today, most sick patients present with multiple chronic conditions (now called "multi-morbid") and increasing psychosocial complexity. Most alarming is that these patients face growing and overwhelming risk resulting from the sum of uncoordinated responses to each of their diseases.

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Topics: care coordination

Care Coordination Roundtable Recap

Posted by Cordata Health

April 6, 2018 at 8:41 AM

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.

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Topics: CoC, case management, care coordination, patient advocacy

Social Determinants of Health Are Waving Their Hands in the Air Begging to Be Noticed

Posted by Cam McClellan Teems

March 16, 2018 at 10:26 AM

There is increasing understanding that social determinants — ranging from poverty and illiteracy to unstable housing and lack of transportation to domestic violence — create tangible barriers to wellness. Even when healthcare providers do everything right in terms of accurate medical diagnoses, proven care plans and effective care coordination, social determinants inhibit a patient’s ability to pursue and reach treatment goals.

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Topics: Barriers to Care

Care Coordination: 2017 in Review

Posted by Cordata Health

January 9, 2018 at 2:02 PM

A Year of Deeper Understanding on the Value of Care Coordination and Management

Saying that 2017 was a busy and consequential year in healthcare would be an understatement. Digital health technology proliferated at an incredible rate. Providers are still figuring out how to adjust to the new mandates for physician reimbursement in Medicare Access and CHIP Reauthorization Act’s (MACRA). The Affordable Care Act was under constant fire from the new administration, with the Republican tax plan effectively eliminating the individual mandate. And value-based care continued to dominate discussions about the future of treatment.

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Topics: Navigation & Care Coordination, Value-Based Care, MACRA

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