Intelligence Report: Care Coordination Considerations

As healthcare leaders recognize the importance of the care continuum, they need to rethink responsibility for care coordination.

This article appears in the July/August 2015 issue of HealthLeaders magazine.

Care coordination in the form of patient transfer is a relatively mature activity, at least in the acute care environment. But new attention to value-based care and at-risk reimbursements means that care coordination is poised for development and growth.

Just over two-thirds (68%) of healthcare leaders say their organization has a care transition function that supports patient transfers to or from hospitals, which is the setting with the highest percentage of supported transfers. Other settings cited range between 40% (for clinics or federally qualified health centers [FQHC]) and 55% (for home health agencies), which gives hospitals a clear but not commanding lead.

Despite the growing expectation that primary care physicians should occupy pivotal spots in care coordination activity, primary care practices are in the middle of the group, with 53% of respondents saying their organization has a care transition function that supports patient transfers to and from primary care. "That means that half the people out there are being coordinated without [a primary care] physician's direct involvement," says Gaurov Dayal, MD, former president of healthcare delivery for St. Louis–based SSM Healthcare, which operates 19 hospitals, an insurance company, nursing homes, home care, hospice, telehealth, and a technology company.

Examining new roles

The presence of care transition activity is related to participation in narrow networks. Slightly more than one-third (35%) of respondents say their organization is in a narrow network, and 31% are not. For every one of eight care venues examined, higher percentages of those whose organizations participate in narrow networks than those that do not say their organization has a care transition function. The difference in care coordination activity between narrow network participants and nonparticipants is especially great for outpatient specialty care (64% vs. 41%), outpatient primary care (66% vs. 46%), and rehabilitation facilities (55% vs. 38%).

Although virtually all interactions between patients and providers can benefit from care coordination, providers tend to focus their efforts (and resources) on patients most in need. Survey results show that diabetes (68%) and heart failure (65%) are conditions for which providers most often currently (or expect to within three years) assign a part-time or full-time staff person to coordinate care. Diabetes and heart failure stand out—COPD is mentioned third most frequently, by 49%.

But as we consider condition-related targeting, Grace Hines, RT, MBA, corporate vice president of systems integration for Sentara Healthcare, a nonprofit health system comprising 12 acute care hospitals and more than 100 sites of care throughout Virginia and northeastern North Carolina, reminds us about the interrelated nature of health problems. "As much as we know these conditions and how to control them," she says, "you've got to get the diabetic patient or the heart failure patient engaged so they can be part of the solution. Often that means you've got to delve into behavioral health issues, too … because many patients have something preventing them from doing what they know is the right thing to do."

So, although only 39% of respondents say they have or expect to have a staff person assigned to coordinate the care of patients with behavioral health conditions, those involved in care coordination should expect to encounter a range of conditions, including behavioral health.

A by-product of targeting is that a small number of patients receive the attention of care coordinators, and a great number of patients are not assigned to a care coordinator—they are on their own to coordinate care. Hines notes that Sentara has an outreach program that assigns quality assurance RNs to work with private practice physicians.

"Quality RNs work with providers to identify aspects of care that can be better managed to improve quality and costs. They explore how best to use the tools and resources of the network to impact patient engagement for the vast number of patients not assigned to a care manager," she says.

Within the acute care environment, the highest levels of clinical integration are seen with outpatient primary care and specialty care (76% and 68%, respectively). Slightly more than one-third of hospitals (36%) and health systems (38%) are clinically integrated with skilled nursing facilities, a count that is bound to increase because relationships between acute care providers and SNFs are the focus of considerable attention due to readmission penalties.

James Newbrough, president of OhioHealth's Home Care Division, says that CMS data helped OhioHealth, which operates 11 hospitals and more than 50 ambulatory sites, notice how close per-patient outpatient spending is to per-patient inpatient spending. "The largest areas [for spending] were SNF and home health," he says. "That probably was a trigger for a lot of people. The lowest-hanging fruit, the biggest opportunities we have to impact postacute spending are SNF and home health."

The SNF environment can be a challenge for care coordination teams. According to Hines, "Even though it is extremely important to go to the right skilled facilities with the right skill sets and capabilities in order to keep that patient from being readmitted to the hospital, there's a big gap in coordinated care. We're finding that they have been understaffed and under-resourced. As a provider team, we're going to have to figure out how to extend our reach and resources to work hand in hand with skilled nursing facilities to engage them in management of patients." The survey results provide a perspective of the very gap Hines mentions. In spite of the industry's attention to SNFs, only 22% of acute care organizations are deploying clinicians to skilled nursing facilities.

Dayal acknowledges that healthcare leaders must examine where the borders with acute care are, not only with SNFs but also with community services. He asks, "Where does our responsibility end? Is making sure that someone is eating healthy and has access to food a healthcare system issue or a societal issue? When we start talking about a population, it's not like a hospital saying that when somebody leaves they're done. [Care is] so interconnected that it's going to require some level of understanding of how the different components connect together and where one's role ends and where the other's begins."

Indeed, although there is plenty of room for improvement among all settings, skilled nursing facilities occupy the bottom of the chart that displays how healthcare leaders appraise the strength of their organizations' care transitions, with just 55% saying their care transition with SNFs is sufficiently strong, and 42% saying they are not sufficiently strong. Nearby on the bottom of the chart are care transitions with outpatient primary care (41% not sufficiently strong) and outpatient specialty care (43% not sufficiently strong). And that may be only part of the story.

Newbrough cautions that not only should healthcare leaders consider the success of the transfers they know are occurring, but they must also develop a sense of whether their care continuum partners are, indeed, receiving the referrals they should. He uses palliative care as an example, noting that 64% of organizations report that their care transitions are sufficiently strong. "It could be that only one out of four patients who should be referred to palliative care or hospice are actually being referred," he says. "Generally, we don't have a strong process for identifying these patients and getting them into those palliative care programs."

Reprint HLR0815-3