In talking to my father recently about his health, I realized just how important care coordination is to the human side of healthcare. In this case, I’m not talking about the rising need for care coordinators in geriatrics or the highly trained care coordinators and nurse navigators who help oncology patients deal with both the logistical and emotional aspects of their treatment. Rather I’m also talking about what we might call the “human factors” in healthcare, those uniquely personal barriers that can challenge good clinical and business outcomes.
For my father, who has always been pretty healthy and ran four miles three times a week into his 50s, the barrier is food. The man loves to eat. He was a foodie before that term existed. And as he has entered his 80s, he still walks 1-2 miles every day with the other seniors at the mall – a place he lovingly calls “God’s waiting room.” But his passion for dining is as strong as ever. In fact, as he ages, dining with friends has become his primary social activity. It is central to his happiness.
As a result of his long-term connection with food (and with a big assist from the US restaurant industry, which thinks sugar is one of the five food groups and that 2,000 calories is good for a meal, not a full day of eating), he has long been overweight. His doctors – both the primary care physicians and specialists he has seen over the years – have always prescribed him to lose weight and to eat less red meat, and more fish and leafy greens.
Honestly, he has tried to modify his diet within the primary life restriction he mandates – that he is going to eat out at least 10 meals a week. So he orders the salmon at O’Charley’s with the broccoli on the side and since he’s eating light, he downs a few of the rolls that come with the meal. If you add up that calorie content, he’s not going to lose weight unless he runs a mini-marathon each day.
Historically, the doctors’ prescriptions have been repeatedly entered into EMRs, where they remain until the next appointment, and the doctors re-enter them yet again. EMRs are systems designed to capture such prescriptions and treatment plans, but they have limited capabilities in making sure those plans are adhered to. And they do very little to recognize the unique and personal barriers to those plans, which vary by specialty and individuals.
In oncology, as an example, patients may be overwhelmed by the emotional factors and require coaching and encouragement from their care coordinators. In spine care, it may be the sheer complexity involved in a treatment plan – multiple facilities, multiple specialists and therapists, and multiple months – that cause patients to drop out of their plans. For any and all types of care, patients may face financial barriers to meeting their copayments or lack convenient transportation to reach their appointments.
All of these real-world barriers to care have potentially significant impacts on the effectiveness of treatment and overall outcomes; and soon they will have significant impacts on the financial health of hospitals and health systems. And this is exactly where care coordination adds value. By recognizing that, first and foremost, patients are people, who may make life decisions that conflict with prescribed care paths, care coordination can help keep patients on track before they fall out of compliance to their treatment plans.
Additionally, and perhaps more importantly, well designed care coordination processes and tools give providers the data and information they need to make adjustments to plans when patients don’t adhere to initial care paths. In this sense, they go beyond EMRs, which only capture the recommendations themselves and don’t provide insights into the barriers or how to navigate them.
In my father’s case, his staunch commitment to live his remaining life on his terms remains unchanged. So, from a care perspective, it’s not a matter of re-prescribing a treatment we know he won’t adhere to, but rather understanding the next best thing he can do, whether it’s a change to his medications or another course.
Again, the problem is common across specialties. Specialties often require the most change in a person’s life patterns. Bariatrics and behavioral care are two specialties where leading-edge organizations recognize that compliance rates are too low. Put another way, that the complexity of treatment plans and the presence of very difficult barriers require care coordination to improve both clinical and business outcomes.
Geriatric care is another area where care coordination can make a real difference. Considering the high cost of the last months of life, palliative care coordination can both decrease treatment costs and help the person/patient who has come to terms with eventual passing have more quality of life in their remaining days. (Atul Gawande has written about this phenomena.) These clinical and business benefits result largely from care coordination’s recognition of the human factor in healthcare.