What Care Coordination Is and How To Implement It

Health care in our country is often fragmented.

Clients often receive treatment for physical health conditions separately from mental illness and substance use. But in reality, they all impact the success or failure of any single treatment plan. And even when there is some coordination between a behavioral health provider and a medical doctor, social determinants like economic insecurity and lack of social supports are often not considered.

Integrated care focuses on the whole person by coordinating physical and behavioral health care along with substance use treatment. There are different models for how integrated care is delivered, but care coordination makes all the difference.

What is care coordination?

Care coordination is the alignment of the various specialists responsible for a client’s care. Organizations adopt care coordination to improve health outcomes and reduce the financial cost of treatments by streamlining care delivery and reducing or eliminating redundancies in care.

Typically, care coordination is put in place by organizations participating in a value-based payment model for populations that are at high risk for comorbidities and/or have chronic physical and mental health conditions. Members assigned to this high-risk category are assigned a care coordinator, which is often paid for by the payer/health plan.

In these scenarios, a care coordinator can:

1. Communicate between multiple providers within the continuum of care, especially with a primary care physician.
2. Identify gaps or duplication in care in areas such as screenings, follow-up visits, medication reconciliation, etc.
3. Intervene with patients or providers to improve care for the sub-population as a whole or on an individual patient basis.
4. Provide patient education, improve engagement, and ensure appropriate hand-offs during transitions of care.

Clients typically receiving care coordination are those from vulnerable client populations. Vulnerable client populations include those with two or more co-occurring and chronic medical conditions. Clients with co-occurring mental health and/or substance use disorders, in addition to one or more chronic medical conditions, also benefit from care coordination.

Care coordination usually is a role that is served by nurses, case managers, or behavioral health clinicians. Care coordinators work in numerous settings including roles in hospitals and outpatient care facilities. In addition, they are used in integrative care settings and in community care behavioral health settings. They take an active stance in managing the utilization of client healthcare services and in improving client outcomes.

Why is better care coordination so important?

Better care coordination can lead to a win-win for everyone: healthier clients at a lower cost to the payer. The care coordination trend goes by many names and has been seen across the continuum of care but has been most prevalent in the Medicaid world as part of the Health Home model.

Accountable Care Organizations (ACO) understand this connection, as evidenced by a poll of ACOs by the National Association of ACOs (NAACOS) and Leavitt Partners, which found that close to 90% feel that Care Coordinators are “very or extremely important to the success of the ACO,” with one participant stating that care coordinators are the “glue connect[ing] a disjointed care delivery system.”

How to conduct care coordination

Clients with multiple medical conditions often require multiple providers and healthcare services. Although pertinent to their care, organizing care efforts from multiple entities can be challenging. This is, in part, due to the inconsistent and sometimes poor, communication between those involved in the client’s care. This can lead to the duplication of services and conflicting treatment recommendations.

When done effectively, care coordination can reduce the burden placed on healthcare providers. To help your organization improve coordinated care efforts, let’s review a few of the effective models.

A public health approach

One of the main functions of care coordination is to eliminate or minimize the barriers that vulnerable clients encounter with healthcare services. This includes proactively identifying at-risk client populations, such as those transitioning from a hospital level of care. In addition, the healthcare team should perform supportive activities to help clients achieve positive treatment outcomes. Thus, care coordination is part of a public health approach toward managing healthcare services to better meet the individual needs of the client. It entails numerous activities that center on client support.

A client-centered, team-based approach

A client-centered and team-based approach is necessary for effective care coordination. This means that services provided to the client are based on their unique needs. It also entails communicating the client’s preferences ahead of time to the healthcare providers involved in their care.

A team-based approach is necessary for care coordination, with team members using effective communication surrounding the organization of healthcare activities. It also consists of a clear delineation of roles and responsibilities associated with care coordination among the treatment team members. When each team member can contribute to activities of care coordination, better results will follow. This means that the treatment team needs to work together to ensure that they meet the client’s healthcare needs.

A team-based approach to integrated healthcare services

In general, care coordination consists of four criteria. These criteria, which are based on an integrated service model of care delivery, include:

1. Multiple service providers involved in the client’s care
2. The sharing of information and skills from those involved in the client’s care. This also means that team members possess knowledge of their specific role on the team and of the available resources to the client that is within their scope of practice.
3. Effective communication between the care team members and client and the client’s supports when indicated
4. The shared goal of working together to improve the delivery of services to the client.