Care Coordination is not a Synonym for Discharge Planning

Facilitating appropriate care entails more than coordinating a discharge plan.   

Review the literature and you’ll find more than 40 definitions of care coordination. In 2007, the Agency for Healthcare Research and Quality (AHRQ), in its landmark paper Closing the Quality Gap, described it as a “deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of healthcare services.” Subsequent publications have been pretty consistent in noting that care coordination activities should be reserved for targeted populations of high-risk or pre-high-risk patients in the community and in the hospital.  

But what gets my blood boiling is that most of the articles, editorials, and research papers that I find among bodies of case management literature focus on coordinating transitions from the hospital to the community, and the value of care coordination in reducing emergency department visits and readmissions. These goals are laudable, but if you go back to the AHRQ definition (as well as others you will find in the literature), it speaks of “facilitating appropriate” care. In my mind, that entails a lot more than coordinating a discharge plan.   

The targeted populations mentioned in the majority of research articles are those with complex medical needs and related underlying factors that impact their health – social, environmental, financial, and cultural. These vulnerable patients would probably meet eligibility criteria for care coordination beginning at the time of hospital admission and extending through community-based transitional care. Many of the more recent studies demonstrate the success of care coordination models that span the continuum, such as The Johns Hopkins Community Health Partnership (J-CHiP) initiative. Their model starts with hospital case managers in two of their East Baltimore hospitals and extends into the community for those patients discharged to local skilled nursing facilities, as well as several ambulatory primary care sites. Nationally, hospital executives and their Accountable Care Organization (ACO) and care coordination colleagues are working behind the scenes to identify community partners and stakeholders that can assist in improving care coordination across the continuum. Working together, they can identify problems and implement evidence-based interventions to address the gaps in care that result in readmissions and avoidable visits to the ED.

While managing the safe transition from one level of acute care to another and from acute care to the community is a given for most hospital case managers, care coordination is the idea that all the hospitalists, consulting specialists, nurses, and care team members are communicating and sharing information to ensure that everyone is acting as a team to meet the patient’s needs. It’s about working together rather than working as separate entities. Unfortunately, this is far from what most patients experience. Breakdowns are everywhere, and they are not exclusive to patients with complex health needs; they happen to all of us.

So it isn’t surprising that when The Commonwealth Fund ranked the healthcare systems of 11 industrialized countries, the U.S. was not ranked highly for its ability to provide coordinated care. In fact, in comparison to the other countries studied, the U.S. placed last in efficiency – largely due to lack of communication among healthcare providers.

At its core, care coordination is just what the name implies: a mechanism through which teams of healthcare professionals work together to ensure that their patients’ health needs are being met and that the case manager is proactively advocating for the right care delivered in the right place, at the right time, and by the right person. This means the following:

•  Sharing information face to face with the care team
•  Expediting internal transitions from critical care areas to limit patients’ avoidable exposure to risk 
•  Engaging and educating patients and families seeking resources to promote self-care
•  Confirming that treatment plans meet patient/family preferences
•  Reporting status and results back to a primary care physician, or to someone coordinating patient care
•  Engaging nursing and care teams verbally and avoiding “chart diving”
•  Practicing resource stewardship to avoid/eliminate wasteful, excessive, and potentially harmful care
•  Meeting with service providers to resolve any resource utilization issues – is there value in serial testing for my patient?
•  Performing persistent patient advocacy to protect patients from clinical or financial harm
•  Reaching out to colleagues to address social, financial, or mental health issues
•  Negotiating with payors for essential services 
•  Conferring with medical consultants, payor representatives, and other parties involved in managing the patients’ care
•  Promoting teamwork by sharing patient goals and making sure each member of the care team is working toward them
•  Promoting team problem-solving to overcome potential obstacles to the progression of care
•  Utilizing technology to bridge communication gaps between team members 
•  Using electronic communication to stay in touch with patients and caregivers
•  Establishing seamless, face-to-face handoffs, when organizational size and geography warrant 
•  Ensuring post-transition follow-up, especially with regard to medication recon and post-acute follow-up appointments
•  Referring to appropriate candidates for long-term transitional care/PHM, especially if they are members of the ACO or a beneficiary of a downside risk contract

In my view, a robust care coordination program, targeting the neediest inpatient populations, pays off in the end. But it requires collaborative networking among all team members for patient-centered expedited care, and it must include real-time partnerships involving people working together to achieve patient-centered goals.  

Over the years, I’ve told client hospitals that care coordination is too expensive to provide to all inpatients and isn’t needed by most. I stand by that advice, knowing that according to MedPAC, around .3 to 25 percent of inpatients are outliers: those patients whose costs or days in the hospital exceed expectations due to the complexity of their medical conditions or their post-acute needs. Those are a hospital’s most vulnerable patients, and in a marketplace punctuated by value-based payment systems, they are the ones who warrant oversight by the hospital case manager to help them and their families through the journey to recovery. When everyone is working together as a team to make sure they are collaborating on patients’ needs, quality of care goes up while costs go down, patient outcomes improve, and satisfaction levels are higher.

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