Five lessons for making your care coordination efforts a lasting reality

As a joke goes about care coordination, if you asked 50 different health care administrators to define it, you might get 100 different answers. To patients and their caregivers, care coordination is no laughing matter.

Care coordination can make the difference toward achieving more consistently positive patient health outcomes. It also helps providers meet several new and increasing outcomes-related financial incentives. Quality care coordination can be difficult to achieve, however, given the time-consuming task of coordinating individualized care within a traditionally mass-scale operational environment.

That was the dichotomy faced by a large health care organization seeking to transform its care coordination from a one-off episodic model to a high-performing, enterprise-wide system emphasizing prevention, quality, affordability and superior patient and caregiver experiences. This organization’s experience provides five key lessons for helping make your care coordination efforts a reality.

Lesson 1: Create and Champion Your Care Coordination Vision

At a leadership level, determine, articulate and champion your vision for care coordination. Do not rely on someone else’s stock definition of care coordination. What matters most is creating a definition pertinent to your organization and the needs and interests of your patients and providers.

Before jumping headlong into a large-scale care coordination transformation, shop your ideas around so you can distinctly know your operational climate. Identify and document roadblocks or challenges that your organization will face. This includes factoring in others’ separate initiatives that might compete for leadership attention and staff resources.

Create advocates and partners for your care coordination vision by telling and re-telling your compelling story of its advantages. Don’t mistakenly believe that everyone already knows why you are doing this or what it means to them and your patients. Instead, regularly appear at staff meetings, do roadshows and use visibility walls to share your story – and gain valuable feedback. It is important to engage others to help them understand the positive changes that can come from care coordination improvements.

Have both a “big picture” vision for care coordination and include specific details of what this will include. For example, your care coordination action details might include examining length-of-stay, managing to narrow networks and supporting provider panel management.

For quantitatively driven colleagues, use data to show how care coordination changes can deliver real benefits. For instance, with a big-picture analysis based on improved documentation and discrete, reportable data, you can show how care coordination can help clinical staff work at the top of their licenses – and even handle growing patient volume.

Lesson 2: Think Big and Create Near-Term Accomplishments

A bold vision that introduces large-scale change requirements, such as introducing or revamping care coordination, requires both long-term goals and short-term or intermediate “wins.” The latter are important for helping clinical and non-clinical staff see the benefits of their care coordination activities – and engage them in longer-term efforts.

Leverage your existing assets to address future needs. For example, start with existing data assets related to care coordination, then use this data to create new dashboards and reporting processes to measure productivity, quality and outcomes.

Our client introduced three key short-term goals into its care coordination transformation:
1. Integrate the in-patient and ambulatory programs into a unified case management team using consistent tools, assessments, care paths and services.
2. Redesign staffing models to include standardized job descriptions, workflows and documentation.
3. Create a centralized care transition services “hub” providing 7-days-a-week coverage to streamline patient transitions to appropriate care settings.

Lesson 3: Team Up to Get Everyone Talking

Clinical staff closest to the daily moving parts of care coordination, such as hospitalists and nurses, can be your greatest allies in your care coordination transformation efforts. Everyone impacted by your efforts can and should add to the conversation. Improving care coordination does not just rest with those directly responsible to coordinate the patient’s care.

This can include getting buy-in and support from key partners and departments, such as IT, finance, and even other clinical departments For example, for our client, this meant addressing disparate systems and varying processes used by the inpatient and ambulatory care coordinators. The organization created a change management team that was prepared to address inevitable pushback to what initially seemed like insurmountable change.

Lesson 4: Document and Act on Workflows

The point of documenting current state workflows from your providers, case managers, care coordinators and social workers is to identify potential inefficiencies. Once you know these, you’ll know what’s possible to improve, from a budget, time and resources standpoint, and what cannot or should not be changed.

Use this as an opportunity to standardize your clinical documentation, a frequently overlooked step. Additionally, document your workflow benefits, such as via key performance indicators. For example, what will be the quantifiable result of delivering complex, coordinated care to your patients?

Lesson 5: Know Your Technology Capabilities and Limitations

Up-front, assess your current technologies to know their capabilities and limitations related to care coordination. Especially for high-value work streams, such as those related to length-of-stay, it is far better to immediately understand what you do and do not have rather than to discover glaring gaps down the road.

For example, as our client was seeking to document items related to expected discharge date, a host of unanswered questions arose, such as: Who is ultimately responsible for determining this? How is it communicated? How does it appear within the system? If you have not thought through the answers to questions like these, your best efforts can quickly become derailed.


Change that ultimately yields positive results is usually preceded by a fair share of digging into the details, conflict, communication and coordination. Improving care coordination throughout an organization is no different, but the five lessons above should contribute to your success. Do not be dissuaded by the challenges. Keep in mind that when everyone enjoys being part of delivering higher-quality patient care, everyone wins!

By Crystal Cooper and Robin Figueroa, consultants, Freed Associates

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.

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