How to close the gaps in care coordination

June 13, 2019

As healthcare continues its slow but steady shift to a value-based landscape, good care coordination is becoming crucial for physician practices to thrive and for patients to get the best care. To coordinate optimal care, primary care physicians, who are often defined as “the quarterback of healthcare,” need to address common gaps in care and recognize the importance of their role. The primary care physician’s role can’t be stressed highly enough, according to Clive Fields, MD, chief medical officer and co-founder of VillageMD, a healthcare management company that supports primary care physicians transitioning to value-based care in Chicago, Ill. Fields says primary care physicians play such a crucial role in healthcare outcomes, that research shows when you add just one more such physician to a population of ten thousand, it results in a 5.5 percent decrease in inpatient admissions, an 11 percent decrease in emergency department utilization and a 7.2 percent decrease in the number of surgeries performed. He says that employers and payers are recognizing that the most important way to drive economic and clinical value in healthcare is a long-term relationship with a primary care doctor. However, he makes clear, “Any physician who thinks he can manage a patient by himself without a team is grossly misled,” he says. “Fragmentation of care is the source of all evil.” “When patients are touching multiple providers with poor care coordination, you get a less than optimal result,” Fields adds.

As healthcare continues its slow but steady shift to a value-based landscape, good care coordination is becoming crucial for physician practices to thrive and for patients to get the best care. To coordinate optimal care, primary care physicians, who are often defined as “the quarterback of healthcare,” need to address common gaps in care and recognize the importance of their role.

The primary care physician’s role can’t be stressed highly enough, according to Clive Fields, MD, chief medical officer and co-founder of VillageMD, a healthcare management company that supports primary care physicians transitioning to value-based care in Chicago, Ill.

Fields says primary care physicians play such a crucial role in healthcare outcomes, that research shows when you add just one more such physician to a population of ten thousand, it results in a 5.5 percent decrease in inpatient admissions, an 11 percent decrease in emergency department utilization and a 7.2 percent decrease in the number of surgeries performed.

He says that employers and payers are recognizing that the most important way to drive economic and clinical value in healthcare is a long-term relationship with a primary care doctor.

However, he makes clear, “Any physician who thinks he can manage a patient by himself without a team is grossly misled,” he says. “Fragmentation of care is the source of all evil.”

“When patients are touching multiple providers with poor care coordination, you get a less than optimal result,” Fields adds.

The value of care coordinators

It’s important, Fields stresses, for physicians to bring a coordinated care manager of some kind on board, particularly for more complex patient populations, to make sure there are no gaps in care.

“[Care coordinators] understand the healthcare ecosystem, they understand the limitations of people’s insurance and what a patient’s goals are,” Fields says.

For example, among a senior or chronic care population, he says, his primary care teams includes transitional care nurses, chronic care managers, diabetes educators and social workers.

Leesa L. Bain, RN, CSN, MHA, vice president of care coordination, quality management and transitions to community living for Cardinal Health Care in Charlotte, N.C. agrees that physicians need care coordinators and should consider having one in-house. “Physicians are experts in diagnosis and determining what treatment should be. We need physicians to focus on what they’re experts in,” Bain says.



“Care coordinators are trained to know how to wrap that patient in services needed to keep them out of crisis, whether that’s an inpatient admission or pertaining to better quality of life for them,” Bain says.

The role of care coordinator is even more necessary given that there is still no integrated system for sharing patient records. “We have different healthcare records, different physicians prescribing different medications, specialists versus primary care in different settings. That fragmentation has provided a heightened need for care coordination as well.”

Bain says that healthcare is only growing more complex and thus, “The navigational component that care coordinators provide is of the essence and it’s growing.”

She urges physicians not to undervalue care coordinators. “They can make the physicians’ job easier if they let them,” Bain says.

Overcoming barriers in coordinated care

Despite the importance of care coordination, there’s a long way to go to close the gaps in care. The NEJM Catalyst’s 2016 Care Redesign Insight Report, which looked at how well care is coordinated between the acute setting, post-acute facilities, and the home environment, found that in only 7 percent of the healthcare facilities interviewed was care fully coordinated, and another 10 percent said care was not coordinated at all.

Michael Casamassa, vice president of solutions and planning for Henry Schein Medical in Austin, Texas, says gaps in coordinated care fall under three key problem areas: Lack of time, lack of financial compensation for coordinated care activities, and technology barriers.
“Primary care doctors are simply too busy and that is likely to get worse unless new disruptive models emerge,” he says.

Casamassa says physicians need to make a choice: “It starts with making a decision on whether or not the office is going to manage care coordination internally or outsource the work to a third party. Someone has to own the care. Without that, it’s incredibly disjointed and expenses start to go up exorbitantly.”

If a physician or practice chooses to outsource, he recommends they use a “turnkey platform” that essentially takes over the care coordination activities as well as manages and analyzes key health metrics that help to intervene upon chronically ill patients.

Other technology that either exists in most practice management systems, or can be integrated into them, he says, are online scheduling programs and referral management programs. Investing in this technology can streamline key aspects of care coordination.

Fields believes that true care coordination can’t be fully outsourced. While there are companies that do product care management, transitional care after you leave the hospital, or collect data, he says, “I’m not sure there is anyone can fully outsource the full suite of services needed, especially for chronic or more complex populations.”

Use data to be proactive

Whatever approach a practice takes to coordinating care, Fields says, “Physicians can no longer sit around and wait to be sure that patients are getting the best care. We’ve got to deliver a more data driven, proactive from of primary care.”

With the advent of artificial intelligence-based data analytics, he says, “We can reasonably predict, based on social determinants of health or disease models, who is likely to need healthcare.”

He recommends that a nurse or nurse practitioner takes on the role of care coordination, particularly for chronic or elderly populations, and uses data that comes directly from the electronic health records to determine their work flow.

“They know in real time who’s been sick, who’s in the hospital, whose lab values are abnormal, for example,” Fields says. “They are reactively reaching out to people rather than waiting for the patients to come to them.”

He gives two examples: One, if an elderly woman becomes a widow, he says she is likely to become more prone to anxiety, loneliness, and depression. Seniors in these situations are also at risk of suicide.

Fields suggests that in cases like these, a single call or check-in won’t be enough to help this patient recover from their loss and integrate back into society. She’ll need consistent follow up.

Another example, he says, is a patient with chronic obstructive pulmonary disease (COPD), who goes to the hospital every September, “Then I’m not a good doctor if I don’t do something about it in August. That’s the tool set physicians will need-the ability to use data to drive proactive interventions instead of waiting for the phone to ring.”

One approach called the “guided care model,” developed out of Johns Hopkins University, validates the value of nurses in coordinating care for patients with chronic diseases such as diabetes and high cholesterol.

In this model, a registered nurse (RN) takes responsibility for patients with more than one chronic condition. The RN makes an assessment of the patient’s care needs, create care plans and teach the patients themselves, and their caregivers, how to manage their particular health conditions. The RNs then work directly with the primary care physician to create a care plan and monitor patients over time, arranging transitions between care settings and helping them access community resources.

One study of this model yielded promising results: total health care costs decreased by 11 percent, with patients saving $1364 annually.

Financial compensation

Fortunately, the Centers for Medicare and Medicaid Services (CMS) has made one aspect of coordinated care a little easier for physicians: they’re now making it possible for physicians to get paid for activities that previously had no reimbursement codes, such as cognitive services, electronic communication with other providers, and transitional care management, Fields says.

Several years ago CMS introduced new CPT codes for chronic care management and remote patient monitoring, for ­example.

“Clinicians are allowed to bill for time that is spent in non-face-to-face clinical interactions,” Casamassa says. This includes such activities as updating care plans, facilitating coordination with specialists, and even monitoring the health metrics associated with chronic care.”

While there’s no single right way to close the gaps in care coordination, Casamassa says, it’s important that physicians start to take steps as soon as possible. “Effective care coordination is central to the overall success of our healthcare delivery system in the United States,” he says.