The other day, during a conversation with two directors of care coordination from two different, large hospital systems, our team had an epiphany about the aggressive market movement to invest in care coordination. As its value has become clearer in the era of Meaningful Use and pay-for-performance, care coordination has become something of an industry buzzword. And like a lot of buzzwords, it’s being applied loosely and liberally, leading to some miscommunication in the market place.
The directors I was talking with were using the term in a decidedly “inpatient” way, with a focus on utilization and discharge management into the outpatient setting. Our team was using the term in an “outpatient” way, focused on managing patients between events at different locations across long term-care paths for complex specialty conditions. The timing is quite different: we view care coordination in terms of months and years, while they think of days or weeks.
We both used the term “care plan,” but with starkly different meanings; they are thinking of follow-up care to an inpatient event, while we think of 12-month or even multi-year plans designed to cure cancer and support survivors well into the future. Before we all move forward at light speed (imagine that, healthcare moving quickly) toward the nirvana that is care coordination, it would be useful to define our terms so we all know where we are going and what we are talking about. So, in the interest of clarity and accuracy, I propose that care coordination may need a few new names or descriptors to cover all the different forms it can take.
Several factors have contributed to the confusion, including the very basic definition of care coordination within the Meaningful Use 3 (MU3) standards and the push from the big EMR vendors (Epic, Cerner, etc.) to add care coordination modules. Currently, many hospitals are turning to care coordination to help them manage cost pressures resulting from ObamaCare, which has them focused on inpatient coordination. They are also faced with the impact of the future implementation of value-based care models that they must consider. But, whatever the cause, the basic issue is that one term – care coordination – is used to describe the radically different processes and capabilities that are necessary to improve outcomes for a wide range of patient types and disease states.
On the one hand, there is the very basic and generic care coordination that typically happens for acute-care patients in inpatient settings. The focus in these situations is strictly on activities that take place inside the hospital itself. The care plan might be no more extensive than “clean the wound after discharge” or “return in 30 days for a follow-up appointment.”
Additionally, there may be a directive to engage social services for the patient, but the verb is “engage,” not “manage” or “follow.” Inpatient care coordination seeks to finish the acute care episode, not to manage the patient as they enter the outpatient, skilled nursing facility (SNF), long-term care or home care arena.
On the other hand, outpatient specialty care coordination for patients with complex or chronic conditions requires a more robust and tailored approach. For example, spine patients may see multiple providers (orthopedists, surgeons, physical therapists, physiatrists, chiropractors) at multiple facilities. The treatment plan might extend across many months or several years. Specific metrics – Oswestry, Neck Disability Index, and STarT Back Tool to name a few – must be tracked to gauge progress or evaluate overall outcomes.
Or consider oncology, where care coordinators and nurse navigators address a much wider range of activities and treatment phases, from risk screening and genetic counseling to support group participation and survivorship. There are different protocols based on tumor types, and complex data requirements to meet different accreditation standards (NAPBC, COC, Joint Commission standards). Active management of common barriers to effective care – including financial, transportation, family and cultural issues – is another big part of oncology care coordination. Care coordination’s role in survivorship – both planning and monitoring – is usually a five-year process.
Compare that complexity to MU3’s low baseline: “patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for more than 15% of all unique patients.” As you can see, outpatient, complex specialty care coordination is an entirely different ballgame than inpatient, acute care coordination designed to hit MU3 standards. We’re talking chess vs. checkers. Or a marathon vs. a hundred-yard dash.
In general, our position is that the more care coordination the better. And many large hospitals clearly need it to improve basic utilization tracking capabilities within their own facilities and to return to financial health. If EMR modules for care coordination help some hospitals instill basic care coordination where there is none today, that’s a good thing. But, it’s important for all stakeholders – care providers, hospital management (including IT) and the community of technology providers – to recognize that EMRs will need complementary tools to handle the unique demands of complex and chronic care coordination. The differences between post-acute and chronic care are simply too great.
This doesn't undercut EMR-centric IT policies, as EMRs will remain a central component in supporting specialty care and still serve as the core system for clinical decision making. The data they capture is essential to effective care in both inpatient and outpatient settings. Specialty care coordination solutions actually extend and enhance the value of EMR investments by supporting broader use of the core data. The payoffs for effectively coordinating care for patients in complex specialties, with chronic diseases or condition and across treatment plans are large. Achieving them will require specialty-specific extensions to the baseline capabilities and functionality EMRs are now offering. This is no surprise, as EMRs weren’t initially designed to do care coordination.
The good news is that EMRs will be able to integrate with some quite mature specialty-specific tools, several of which have been in use at large hospitals for many years. Front-line care coordinators, as well as service-line directors and physicians, have helped solution providers develop the specific features and functionalities and data requirements they need for their specialties.
General inpatient care coordination. Specialty or complex care coordination. As the market matures, stakeholders may come to understand these different flavors or levels of care coordination. But for service line leaders in oncology, spine and other complex specialties, this is more than a matter of semantics. They may be facing pressure to move to one big solution for care coordination as a part of a system-wide consolidation effort. On paper, that may seem to make economic sense, but if it limits hospitals to MU3’s rudimentary criteria for care coordination, patient care, patient satisfaction, patient outcomes and hospital ROI will suffer.In fact, given the clear business case for and proven track record of care coordination, we believe hospitals must think in terms of a complement of tools that suits their unique mix of specialties. That is how care coordination can deliver fully on its compelling value proposition of improved clinical and business outcomes.