Improving Care Coordination: 3 Best Practices

Care coordination is a strategy focused on providing cohesive patient care across healthcare facilities. Rather than allowing care to get fragmented, this strategy promotes unified care plans that put patient needs and preferences first. When done well, it can create cost savings for facilities and help patients achieve optimal outcomes.

The widespread use of electronic health records (EHRs) and emphasis on person-centered care have supported the movement toward higher levels of coordination and collaboration among providers. However, clinicians must still navigate multiple barriers on a daily basis, such as time constraints or difficulties sharing information between incompatible platforms.

The federal government and private insurance companies encourage coordination through financial incentives (and penalties for fractured care), making a shift to this model a financial necessity. In this guide, we’ll answer questions about coordinated care, and give you three best practices that you can implement with your team.

Care Coordination: Definition and Overview

Coordinated patient care is a person-centered healthcare delivery model that focuses on:

• The timely exchange of information between providers.
• Collaborative efforts to help patients reach their health goals.

For example, within this model a patient with cancer could receive care from a primary care provider, an emergency room care team, and an oncologist — all functioning as members of a broader team working toward the patient’s goals.

Coordinating Healthcare Services: FAQ

Here are answers to some commonly asked questions about this important care delivery model.

What is the importance of care coordination in nursing and other healthcare disciplines?

The coordination of care services helps nurses and other providers deliver optimal, cost-effective care. The approach promotes effective, efficient care by:

• Closing care gaps (e.g., between hospital discharge and home care).
• Promoting timely interventions.
• Reducing testing redundancies.
• Reducing medical errors (e.g., conflicting treatments).
• Reducing medication mismanagement (e.g., duplicate therapies).
• Reducing hospital readmission rates.

How has the coordinated care model evolved?

While this approach emerged informally decades ago, for a long time it was the exception rather than the norm. For the most part patients were responsible for overseeing coordination between services. For example, patients frequently brought paper copies of records, medication lists, or test results from one clinician office to the next.

This changed with the widespread implementation of EHRs as a means of storing patient health information, which opened up the possibility of creating records that were easily and quickly shared between organizations. In theory, digital health records facilitate coordination between agencies.

What policy changes promoted care coordination services?

The Affordable Care Act went into effect in 2010, creating Accountable Care Organizations (ACOs) which formalized the shared responsibilities of healthcare organizations. The Centers for Medicare and Medicaid Services (CMS) pushed coordinated service models into more prominence by creating coordination-related billing codes and providing financial rewards for efficiency.

What are the key elements of coordinated patient care?

While exact definitions may vary, core concepts of the model are explained below.

What are the consequences if care is not properly coordinated?

When care is fragmented (or siloed) between agencies, patients can quickly get overwhelmed by the logistics of navigating the landscape. Failures involving lack of communication, or miscommunication, between clinicians cause mismanaged conditions. Poor transitions between the hospital and home can lead to unnecessary readmissions, which can have a negative impact on the patient and the hospital’s reimbursement rate. Overall, patients struggling to patch together services from distinct and uncooperative providers may feel frustrated and unsatisfied with their care.

What is a coordinated care organization (CCO)?

This is a type of ACO that is composed of a network of healthcare providers. It’s also referred to as an accountable care model, and is primarily used by the state of Oregon to organize comprehensive care for patients paying with Medicaid. Other states, including New York, use CCOs to help manage care planning for certain patient populations.

What is care coordination in mental health?

While many healthcare services have increased their coordination efforts, mental health providers sometimes get left out of the loop. Historically, mental health and physical health have been separated. Care coordination, in a mental health context, refers to specialized programs or services that seek to connect mental health service providers to other members of the patient’s care team. One example of this is Intensive Care Coordination (ICC) programs that have been implemented to help children and teens with complex emotional health needs.

3 Best Practices for Improving Coordination of Patient Care

The focus on coordinating services across facilities and agencies is very different from traditional, episodic models of healthcare delivery. Figuring out how to build this new approach into existing workflows can be a challenge. Here are three evidence-based strategies that you can use to improve your facility’s capacity to coordinate care services.

1. Ensure Coordinators Have Appropriate Training

CMS commissioned a report to examine best practices for providing coordinated healthcare services. The researchers found that the professionals charged with overseeing coordination should be RNs with a minimum of a BSN. Successful coordination programs also employed nurses with prior geriatric and community nursing experience. These qualities help this key point person problem-solve, coordinate care with community resources, and detect functional health deficiencies.

Example: A med-surg unit hires a new patient care coordinator who holds a BSN. Her background as a public health nurse providing education to underserved populations helps her understand the needs of her patients.

2. Encourage Clinicians to Read Interdisciplinary Notes Before Engaging With the Patient

Collaboration among providers contributes to patient trust. Data shows that when patients view distinct providers as members of a larger, unified team, they have more confidence in their treatments. Encourage your care providers to act as parts of a broader team by taking advantage of shared information.

Example: Instead of asking, “How did it go with your cardiologist?” a nurse practitioner may say, “I saw that Dr. Lee put you on a blood thinner on Wednesday. How has that been going for you?”

3. Prioritize EHR Interoperability

High-quality EHR systems are compatible with other systems, facilitating the seamless (and secure) exchange of information between agencies. This helps clinicians access current, accurate information about their patient’s health status. EHR interoperability has become the gold standard for health information exchange, but some outdated systems are not up to this standard. If your facility is using an outdated system, prioritizing an upgrade could improve your information sharing practices with other providers.

Example: A healthcare clinic purchases cloud-based EHR software from a certified vendor to improve information exchange with other healthcare offices in the area.

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