Creating a care coordination infrastructure to achieve triple aim goals

Realizing improved financial and patient health outcomes by emphasizing prevention instead of intervention has been a challenge for healthcare organizations to achieve in our fragmented healthcare system since the 1990s. While technological advancements have increased access to preventive health services — including screenings, health behavior counseling, and immunizations —Americans receive only 50 percent of these recommended services. Avoiding financial penalties is also an increasing challenge for more than 2,600 hospitals that will lose Medicare payments in 2015 as a result of having an excessive number of hospital readmissions within 30 days of discharge.

Creating a care coordination infrastructure to manage patients across the care continuum is essential to achieving the Triple Aim goals of improving the health of populations, reducing costs, and enhancing the patient care experience. As healthcare providers move toward adopting accountable care models, they will need to shift their investment focus from health interventions to preventive health services to cost-effectively achieve pay-for-performance goals. In addition, healthcare systems in New York and Texas can capitalize on Delivery System Reform Incentive Payments (DSRIP) grants, which offer incentives for developing innovative care coordination initiatives.
While healthcare organizations may not be able to control patient healthcare and lifestyle choices, they can influence decision-making by creating an effective care coordination framework. Below are steps to create care coordination foundation that drives patient engagement:

- Define target populations to create a roadmap for initiatives. Only 10 percent of respondents in a recent HealthLeaders survey have committed to improve the health of a defined population. Identifying why, what, and how populations should be targeted involves a comprehensive assessment to determine the most cost-effective use of resources, which would align with organizational goals. Will populations be categorized based on their risk, diagnoses, and geographic locations? Will diagnosis-related groups (DRGs), LACE scoring, and / or propriety predictive algorithm tools be used to identify populations? From patient-centered medical home development to clinical IT decision support and community partnerships, what additional resources are offered across the continuum of care? Answers to the questions will align resources with organizational priorities.
- Conduct an assessment to prioritize community partnerships. Cultivating and maintaining relationships takes work. Choosing the right partners can make all the difference in providing an integrated continuum of care that will achieve desired patient outcomes. Identifying community partners — including public health departments, human services, faith-based organizations, and volunteer programs is a time-consuming process. It requires developing a collaborative partnership for resources to contribute to positive patient outcomes. This is a labor-intensive, time-consuming task. Senior leadership needs to consider outsourcing options to capitalize on the assessment needs.
- Create a governance structure that drives communications and accountability among stakeholders. Building an integrated governance framework can be challenging, but the importance cannot also be understated. A strong governance structure will guide development of a successful framework by securing executive leadership support, establishing new roles and responsibilities, driving effective communication, managing organizational change, and creating measurements for success. Setting expectations regarding roles and responsibilities is crucial to building a working structure that can support change.
- Build IT platforms around familiar care management workflows. Adopting new population health management software and moving from paper, manual documentation processes is a significant change for clinicians. Implementing such changes can be frustrating for staff and lead to ineffective use of costly IT software. Automating workflows will reduce wasteful, redundant documentation efforts and provide an increase in time spent in actual patient care. It is important to include care coordinators in software implementation and adoption from the start to prevent future problems by ensuring usable and efficient workflows, which will meet staff and patient needs.
- Invest in integrated clinical data and analytics platforms across the patient care continuum to inform decision-making. Healthcare organizations will need to shift from investing in buildings and facilities to developing integrated clinical and analytics IT platforms that can be accessed by providers across the healthcare enterprise. Today's technology can alert care coordinators to current patient care gaps and guide appropriate interventions. Instead of using old, retrospective data, care quality improvement efforts across the continuum can be met with clinically integrated data and analytics.
- Use tools to promote patient engagement and influence behavior change. Motivating patients to make lifestyle and health changes is one of the greatest challenges faced by healthcare organizations. The patient portal is an emerging communication tool to support patient engagement by providing access to the patients' clinical information, such as lab results. In addition to the portal, mobile device app monitoring can improve patient-clinician communication. Telemedicine is also expected to be one of the largest areas of investment for healthcare organizations in the near future.
- Establish realistic measures and benchmarks that give an organization time to meet goals. Determining targets for outcomes needs to be defined from the onset of program initiation. Outcomes can include a variety of metrics, such as improving immunization rates or appropriate use of diagnostic imaging for low back pain. In addition to determining what metrics will effectively capture your population health management efforts, it's important to factor in an appropriate timeline for effective change.

While defining populations, cultivating collaborative partnerships, creating governance structures, integrating IT platforms, and establishing metrics are common elements to approaching a care coordination framework, a "one-size-fits all" approach cannot be applied to population health management initiatives. Conducting thorough assessments is essential to identify and integrate the right populations, partners, processes, and technologies to reduce costs and achieve successful community health outcomes.

1 Krist, A.H., Shenson, D., Woolf, S.H., Bradley, C., Liaw, W.R., Rothemich, S.F., Slonim, A., Benson, W., Anderson, L.A., (2013, October). Clinical and community delivery systems for preventive care: An integration framework. American Journal of Preventive Medicine. 45(4), 508-16. doi: 10.1016/j.amepre.2013.06.008. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24050428

2 Rice, S. (2014, October 2). More U.S. Hospitals to receive 30-day readmission penalties. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20141002/NEWS/310029947

3 HealthLeaders Media. (2014, October). HealthLeaders Media Population Health Survey. Retrieved from http://www.healthleadersmedia.com/content/QUA-309676/Slideshow-Population-HealthmdashAre-You-as-Ready-as-You-Think-You-Are##

4 Mace, S. (2013, November.) Population health and the analytics opportunity. HealthLeaders. 26(9), 11-24.

5 HealthLeaders Media. (2014, October). HealthLeaders Media Population Health Survey. Retrieved from http://www.healthleadersmedia.com/content/QUA-309676/Slideshow-Population-HealthmdashAre-You-as-Ready-as-You-Think-You-Are##

 

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