Care Coordination

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Care Coordination is a deliberate process involving organizing and sharing information and activities among all the participants in patient care with the goal of achieving safer and more effective outcomes. From the patient perspective, the goal is to understand the patient's needs and preferences and well as the healthcare infrastructure so high-value care can be optimized, delivered, and utilized. From the provider and system perspective, the goal of care coordination is to help patients effectively navigate the healthcare system and for the system itself to provide effective and high quality care which leads to improved outcomes in both health and cost.[1]

How is Care Coordinated?

The Agency for Healthcare Research and Quality has highlighted a number of activities that are involved in the process of care coordination[2]:

  • Establishing accountability and agreeing on responsibility
  • Communicating/sharing knowledge
  • Helping with transitions of care
  • Assessing patient needs and goals
  • Creating a proactive care plan
  • Monitoring and followup, including responding to changes in patients' needs
  • Supporting patients' self-management goals
  • Linking to community resources
  • Working to align resources with patient and population needs

The goal is to utilize the available resources of the patient, community, and healthcare infrastructure to serve the patient's needs and preferences.

The Role of Informatics

With the advent of electronic health records, there is an increased opportunity for improved care coordination. EHRs have an advantage over traditional means due to their data structures. With a rich wealth of patient data, fairly simple extraction, and ability to track patients longitudinally across providers and settings, EHRs have the potential to greatly expedite care coordination. However, there are a number of barriers which prevent EHRs from fully functioning in the care coordination system. Lack of standardization and interoperability of data and systems is a huge barrier to proper care coordination. This highlights the need for standardized quality measures and incentives for the providers and systems to meet these standards. More of this is explored in meaningful use.

Patient Centered Care

Because a patient can have a number of providers - physicians, nurses, pharmacists, social workers - within a single care practice, it's no shock that coordination inter- and intra-system can prove to be a challenge. In this case, the EHR must be able to function between a variety of users and workflows in order to be effective. There also must be a system in place not only for providers to communicate effectively between each other, but also to communicate with patients. The same principles need to be in place when focused on care transition. The flow of information and communication must be robust not just between a single healthcare team but potentially among multiple teams at multiple facilities.

Technology Supported Care

Technology itself can be a useful tool in the care coordination process by providing the infrastructure itself for care coordination. Telehealth and telemedicine can help bridge the communication gap between providers, other providers, and patients. Telemonitoring can help to provide more information to caregivers. Additionally, personal health records, as well as the technology to access those records, can help to improve care and coordination. If a patient is able to access their information on a personal or portable device, it can lead to improved engagement and health literacy. CDS systems are another layer of technology that can improve coordination by allowing users to access a greater wealth of knowledge.

Technology Supported Quality

Technology can also support care coordination by serving the healthcare infrastructure.

[3] [4] [5]

Submitted by (Tony Zhou)