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The three C’s of cross-continuum care coordination

Luis Castillo, CEO Ensocare
Written by: Luis Castillo

There has never been a better time to shore up care coordination across the continuum. Emerging value-based payment opportunities along with penalties directed at hospitals for unnecessary readmissions are prompting healthcare organizations of all sizes to find ways to improve quality, reduce costs and prevent return visits to the hospital; enriching care coordination is one strategy for realizing these goals. When hospitals, post-acute providers, home care agencies, patients and families work together to ensure patients are engaged in their care, follow treatment plans and get help before chronic conditions take a turn for the worse, better long-term health outcomes can be achieved for patients while limiting unplanned trips to the acute setting. This can result in higher quality scores, enhanced patient satisfaction and reduced costs.

Cross-continuum care coordination is a relatively recent concept for healthcare organizations, and some are discovering just how best to enable this high-level of interaction. This approach is unlike the traditional way of doing business in which healthcare organizations operated in silos, focusing on their care processes and procedures within their four walls.

This inwardly-focused mindset is quickly shifting. By embracing the following three concepts, organizations can greatly enhance their relationships outside of their walls.

Facilitate communication
Robust communication should serve as the foundation for any effort to boost cross-continuum coordination. The easier it is for providers in different settings to share details about a patient, the more likely it is that care transitions will be smoother and the patient’s overall treatment plan will continue without disruption. Communication should be timely and efficient and focus on relevant details.

Technology can foster solid communication. For example, care coordination solutions can support faster information exchange between hospitals and post-acute providers, as well as provider to provider, and between home health staff to hospital personnel. More advanced technologies can virtually eliminate manual processes, such as faxes and phone calls, enabling more time for patient interactions.

Such solutions can also facilitate seamless sharing of essential portions of a patient’s medical history and current needs. Depending on the patient, medical records can be quite large and difficult to navigate—sometimes hundreds of pages long. Providers only want to receive the information they need to continue therapy and make appropriate treatment decisions. With technology, providers can electronically send the pertinent information to the next level of care and ensure a smooth care transition.

Cultivate collaboration
To effectively coordinate care, organizations need to go beyond merely sharing information. Healthcare providers must be able to react to data they receive and take the appropriate next steps to respond. Without a focus on collaboration, key warning signs may go unnoticed or critical information may slip through the cracks.

Again, technology can help. Consider a hospital that sets up an electronic command center through which all members of a patient’s care team, including the hospital care coordinators, post-acute providers, primary care physicians and patient and family share information, monitor treatment compliance and receive alerts as to concerning changes in the patient’s condition. All providers are kept up-to-date and can rapidly respond if there is a worrisome trend. Not only can this prevent a return trip to the hospital, but it can ensure the patient consistently follows his or her treatment plan.

Enable connectivity
As discussed in the previous sections, technology can facilitate stronger communication and collaboration. However, for technology to be truly useful, it must be interoperable with healthcare organizations’ other systems. If a system is hard to navigate or requires extra steps, staff won’t be as likely to use it. For instance, if care coordinators have to log out of their electronic health records and log into a care coordination tool, and the two technologies do not integrate or share information, it will be cumbersome and restrict optimal use, furthering staff dissatisfaction.

Mobile technology can be especially helpful in improving connectivity. Providers can get critical patient updates on their tablets and phones, receiving information anywhere without being tied to an office or desk. For example, when hospitals send information to post-acute providers about a potential patient, the post-acute staff can receive this information while working with other patients or addressing other issues. They can respond quickly in real time without having to leave their current task or patient and return to the office.

Patients can also benefit from mobile solutions when they are discharged home. Individuals can easily upload information from Bluetooth-enabled technology, such as scales or blood pressure monitors, and share their outcomes and metrics with providers. Alerts on phones or tablets allow staff members to learn in real-time if a patient has an issue and requires assistance.

Making a vow
Although healthcare organizations across the spectrum are just starting to adopt technology to enable cross-continuum care coordination, those that embrace the concept are seeing real benefits. By vowing to improve communication, collaboration and connectivity, organizations will be better equipped to work in tandem to enhance the quality and safety of patient care.