What is Careful Care Coordination? 

Care coordination is a key aspect of effective healthcare, particularly when patients are under the care of multiple healthcare providers. A care plan for someone with a chronic or ongoing condition may require the intervention of various medical professionals. Without careful care coordination, data can be lost, messages can be missed, and treatment plans can be disrupted.

Understanding the importance of care coordination helps practices work more effectively with other providers and partners to enhance patient outcomes. 

The Fundamentals of Care Coordination

Patient care has four primary pillars: 

• First Contact, which is the initial appointment or conversation with a healthcare professional. This may take place in the doctor’s office, the emergency department, or when using any health service.

• Comprehensiveness, which covers providing thorough and appropriate care throughout every appointment, follow-up, and treatment plan.

• Coordination, which ensures the effective integration of every health service and clinical professional required to treat the patient.

• Continuity, meaning the continued application of care as necessary.

Coordination is key because there are cases where patients must receive care from more than one individual or organization. Effective care coordination is one example of interoperability in healthcare, where systems and people from disparate providers work together for positive outcomes. 

Creating an effective care plan requires a full understanding of patient needs. Care plans must take into account patient safety, from mobility issues to medication allergies, and even mental health concerns. Without effective care coordination, a patient may be passed to a provider without the relevant safety information in place. This can lead to providers inadvertently causing harm because they don’t have access to correct data that helps protect patients and promote positive outcomes. 

How Careful Care Coordination Impacts Patient Outcomes

An effective care team can be comprised of doctors, nurses, mental health professionals, specialists, physiotherapists, social workers, and many more. The right interventions at the correct time by the appropriate clinicians can be the difference between positive and negative health outcomes. 

An effective care team should also coordinate with in-home caregivers, whether that’s a spouse or other family member, or ambulatory nurses and carers. Care coordination may also include teams at nursing homes or supported living environments. The more complex the care needs of the person, the more important effective coordination becomes.

The American Hospital Association reports that treatment for hospitalized patients becomes more effective when full information is quickly gathered and passed along from the emergency medical services (EMS) teams to the receiving clinicians. Effective transfer of data, often utilizing optimized electronic health record (EHR) systems, can strengthen trauma response and recovery. 

Health outcomes are also improved when ambulatory care providers have access to data from every aspect of a patient’s care team. Effective coordination between mobile providers, caregivers, social services, and primary healthcare providers can cut mental strain on medical professionals while reducing hospitalizations and provider costs. 

Coordination in Chronic Care Management 

Care coordination is particularly important for patients who suffer from chronic conditions. Chronic conditions are often complex, long-lasting, and have various impacts on the individual’s overall well-being. A lack of mobility, for example, can have a lasting detrimental effect on a patient’s mental health. Diabetes may lead to problems with eyesight and other complications. Many complex diseases require intensive bouts of medication, which can result in liver and kidney problems.

When patients develop multiple, interconnected issues stemming from chronic disease, care coordination becomes vital. Chronic care management requires teams that communicate effectively and technological tools that collect and deliver data swiftly and securely. Without effective coordination of care, patient outcomes can be severely impacted.

Conversely, when teams and providers work together synergistically, patients can enjoy a better quality of life. As well as face-to-face interactions, therapies, and physical procedures, services like telehealth, wearable technology, and digital apps can all be part of care coordination for chronic illness. Wearable blood pressure monitors can send real-time data to clinicians. For example, who can give caregivers or ambulatory providers immediate updates if there are any concerns. Apps can log daily health metrics, and send reports securely as needed. All this data can be collated in integrated EHR systems for swift retrieval as required. 

Care Coordination and Reimbursements

Another factor to consider is the fact that some practices are eligible for reimbursement for providing effective chronic care management. In cases where patients have two or more chronic conditions, the Centers for Medicare and Medicaid Services (CMS) insists that these patients have a formalized chronic care management (CCM) plan.

These CCM plans often include multiple providers and clinicians. The CMS stipulates that plans must include prioritized communication between patients, caregivers, and providers, and cover methods for effective care transitions. Care coordination is at the core of these requirements. Being able to demonstrate that CCM plans include effective coordination of care genuinely enhances patient outcomes while helping to ensure that practices receive the reimbursements due to them. Accurate reporting and timely submission of reports are also essential aspects of this. 

How TempDev Helps Practices Achieve Careful Care Coordination

Whether you’re a large practice with multidisciplinary teams or a smaller practice working with remote partners, the right support for your electronic practice management (EPM) and EHR systems is essential for effective care coordination. Fast access to the right patient information promotes prompt decision-making to help patients along their treatment journeys at an accelerated rate. Effective digital systems also help with patient engagement, via online portals and other ways to help individuals be more proactive in their own health management. 

TempDev’s team of NextGen experts helps you optimize your EHR workflows to better capture data from phone calls, face-to-face appointments, and referrals from other providers. Streamline pathways from the first appointment to finalized treatment plans, by combining patient data, lab results, and insights from clinical staff. Personalized templates prompt the collection of relevant data while workflow optimization ensures that data is sent to the relevant parties for enhanced coordination of care.

Contact TempDev to find out how we can help you leverage NextGen to elevate care coordination and enhance patient outcomes.