As key provisions of health care reform kicked into high gear after the passage of the Affordable Care Act in 2010, there was an upswing in the hiring of care coordinators, a relatively new job title focused on coordinating a patient's path to health.
Now, two industry developments are raising care coordinators' profile in clinical settings, and will likely encourage health care organizations to bring even more on board.
First, the Centers for Medicare and Medicaid Services signaled it would continue to push for value- and risk-based care models. Second, a proposed CMS rule from October 2015 displayed new requirements for discharge planning that focus on the patient's wishes. Value-based care and patient-centered discharge planning go together like a hand in a glove, and both tend to rely on care coordinators for success.
Value-based payment models, such as the Bundled Payment Care Initiative, incentivize high-quality care without readmissions. Hospitals will begin to receive a target price for each episode of care and must continue to bear financial risk for the costs of the patient's treatment for the episode – usually 60 or 90 days. If patients are readmitted, the cost of the readmission counts against the hospital's spending benchmark. This has put enormous pressure on identifying patients at risk of readmission and identifying the appropriate next-step in the continuum of care, whether that's a skilled nursing facility or home health.
There is a very strong business case for reducing readmissions and improving post-acute care transitions, and the task of coordinating discharges, evaluating patients and explaining their options often falls to care coordinators.
As the industry anticipates bringing more care coordinators into the fold, here's a quick look at the four ways this role helps meet the goals of improved PAC transition and discharge planning.
Understanding patient needs: The primary job of care coordinators tasked with developing discharge plans is to make sure that patients go to the right setting – whether that's home, a skilled nursing facility or another facility. To do this, they collect data for initial assessments, such as patients' medical history and functional level. But they may also have to ask in-depth questions about a patient's home and community resources. All of this information can be used to evaluate how successfully a patient can recover in each setting.
Coordinating across the continuum: The role of the care coordinator doesn't stop with an initial assessment. Many care coordinators are poised to handle challenges outside of the hospital. That entails ensuring patients attend follow-up appointments and adhere to their medication regimen. In some cases, care coordinators may help patients evaluate PAC facilities and even visit the facility to make sure their patients are getting proper treatment.
Improving outcomes through data analysis: In addition to understanding individual patients, providers are increasingly turning to technology to look at overall health outcomes. When it comes to post-acute risk, this includes systems that make evidence-based risk assessments and recommendations for referrals. These tools determine what facilities had the most favorable outcomes for patients with the same diagnosis, giving care coordinators the confidence they need to have frank discussions about where a patient should be discharged to. Care coordinators go beyond collecting much of the information that feeds into the data tools. They may also conduct research and data analysis on health outcomes, and make recommendations to further refine the discharge planning process.
Advocating for patients: Care coordinators need to be creative problem solvers and effective communicators. They're passionate about making a difference in a patient's personal recovery journey, but they must also be resourceful and resolute in navigating care for patients with complex conditions or for patients who lack routine medical care. Care coordinators work across the care team with doctors, nurses, social workers and even administrators. Their or position empowers care coordinators to become a contributing member of the care team, make recommendations, and, when needed, advocate for what's best for the patient.
The business case justifying the investment in new employees or training for existing staff to become care coordinators is clear: Care coordinators help hospitals and health systems save money by reducing internal costs. The rise of value-based and person-centered care make care coordinators even more important. If the U.S. is going to slow the rise of PAC spending, care coordinators are a key asset -- and they can meet that goal without skimping on measures that generate positive patient outcomes.
About the author:
Karen Chambers serves as VP of Clinical Quality Management for naviHealth (www.naviHealth.us), and is responsible for enterprise-wide clinical model design, quality measurement, learning, accreditation, clinical strategy, clinical information systems and high-risk case management. naviHealth uses evidence-based technology and patient engagement to optimize transitions to post-acute care settings.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.