By Jackie Birmingham, RN, MS
One of the objectives that hospitals must achieve in order to receive American Recovery and Reinvestment Act incentive money for the meaningful use of electronic health records is to improve care coordination. Yet the meaning of care coordination seems to be a mystery to many and a misconception to others.
Here’s what it’s not: It is not just a handoff of a patient to another care provider or level of care. Rather, it is that and more. Much more.
Care coordination is the smooth, real-time and collaborative transition of patient care from one caregiver or team to another, based on what you’ve learned from multiple patient episodes. It’s a systematic and efficient way to ensure that the appropriate, medically necessary services are available for your patient population where and when they are needed.
Hospital staff represents one part of the continuum of care. Post-acute providers are another. Both are integral to care coordination. Working together during patient transitions is care coordination at it most effective.
Improving Care Coordination.
To demonstrate enhanced care coordination, you need a three-pronged approach built around:
A provider road map. No one can do everything at once, so set priorities. Given your patient population, determine who is most frequently in need of post-acute services. If, for example, you have a stroke service and discharge patients for rehabilitation, develop and keep updated a list of key providers that you can offer to patients so they can receive needed post-acute services in a timely manner. This is a foundational element to care coordination. You have to know who you’re coordinating with
Technology. Paper and pencil hash marks don’t cut it anymore. You must be able to exchange key patient-specific clinical information securely and quickly with providers. Given clinician-to-patient ratios and the seemingly never-ending stream of mandatory forms, wasting time on hold or at an open-for-all-to-see fax machine is not effective. (And in the case of unprotected faxing, it’s a HIPAA violation waiting to happen.) No one piece of technology will be a hospital’s silver bullet, but you can start by
focusing on one part of the continuum of care, patient transitions.
Data. Part of care coordination is continuous improvement in the way you provide care. This is where a rigorous and regular review of data comes in. By tracking readmissions by diagnosis or physician, LOS-related metrics as well as provider acceptances and response times, you’ll be armed with the business intelligence that highlights gaps in service or quality that you can address with fellow providers. That brings care coordination full circle. You’re continuously communicating and collaborating about patient care in a systematic way.
Jackie Birmingham, RN, MS is vice president of regulatory monitoring and clinical leadership at Curaspan Health Group.
Related Links:
> Looking for a Transformation in Health Care? Look at Data
> Better Communications Leads to Better Care
