I grew up as the youngest of 2 girls in a tight knit family in the Midwest.  We were a pretty regular family by most people's definition. Though I went on to college, marriage and family while maintaining a fulfilling career in Software, my sister had a very different path. After a tumultuous period in late middle school, my sister began smoking, experimented with drugs and alcohol, skipped school, ran away several times and even tried to commit suicide more than once.  In high school she found some equilibrium and graduated, in part, due to the steadying influence of a long-time boyfriend. However, she became pregnant shortly after graduation from high school and then tragically lost the father of the baby to a drowning accident. She went on to struggle to provide for herself and her child. Due to underlying mental illness (depression, anxiety, borderline OCD and borderline bi-polar), she struggled with drug addiction, alcohol abuse, abusive relationships, and run-ins with the law. In addition, she had chronic pain in her neck and severe asthma. 

What does this have to do with Care Coordination, you might ask? Everything!  Because of her mental health diagnoses, my sister was on Medicaid and Supplemental Security Income (SSI).  As a smoker with anxiety disorder leading to panic attacks and shortness of breath, she had frequent breathing crises that led her to the Emergency Department for intervention. While she took medicine for Asthma, anxiety, depression, and neck pain, it was clearly not controlling her illnesses.  Ultimately, my sister died of an asthma attack at the age of 33 years old, leaving behind 3 children.  Here's the question that kept running through my head: "How can someone in this day and age die of asthma while under treatment and being seen regularly by physicians?"

So what exactly is Care Coordination and what does it have to do with my sister? Care Coordination is the idea that by having someone focused on coordinating integrated health care for a population of members a payer is financially responsible for, they can expect to improve both the member health outcomes and the financial cost of those outcomes. 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. In these scenarios, a Care Coordinator can:

  1. Communicate across 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-off during transitions of care


Better Coordination of Care

Better coordination of care for members can lead to a win-win for everyone (healthier members 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, in particular as part of the Health Home model.  The State of Missouri instituted Behavioral and Primary Health Care Homes using Care Coordinators (called Nurse Care Managers) that has seen phenomenal success.  For their Behavioral Health Care Home population, which was defined as individuals experiencing Serious Mental Illness (SMI) in combination with 1 or more chronic illnesses, Missouri saw a cost savings of $31 Million during the first year alone.  One way Missouri accomplished this incredible cost savings is by requiring that all members receive a metabolic syndrome screening.  This was prompted by the realization that only about 12% of their membership had a metabolic screening on file in the previous 12 months.  To incentivize adherence to this requirement, Missouri would not allow new members to be assigned to a Health Home that did not keep its metabolic syndrome screening rate above 80%.  Given that having more members means having access to more funds to manage the population's care, this was a powerful incentive.  Each Health Home utilized Nurse Care Managers to accomplish this goal, among others.  Missouri attributes much of this financial improvement to a reduction in unnecessary hospitalizations and emergency department visits.

Accountable Care Organizations (ACO) understand this connection, as evidenced by a recent poll of ACO's 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 coordinators are the “glue connect[ing] a disjointed care delivery system.”

At this point, I'd like to return to my sister's situation.  She was certainly experiencing Serious Mental Illness in combination with a chronic illness (Asthma).  I can't help but wonder if her death was entirely preventable if she had been under the watchful eye of a Care Coordinator such as the Care Managers employed in the Missouri Health Home model.  Using a Population Health management tool, they likely would have noticed that she was showing up in the Emergency Department on a regular basis.  They surely would have noticed the combination of both Physical and Mental Health diagnoses.  Would that Care Manager have stepped in and communicated with a Primary Care Physician (PCP), her Psychiatrist and the Emergency Department where she was a frequent visitor to identify more effective ways to treat her chronic conditions?  Would encouraging her PCP to take a close look at her medications reveal the reason why her Asthma was so poorly controlled?  Could she have been encouraged and supported through a smoking cessation program?  Perhaps some education on controlling Anxiety would have led to fewer panic attacks, and subsequently fewer panic-induced asthma attacks? 

Sadly, my sister did not have the opportunity to benefit from proper care coordination.  However, we can look at how care coordination has already impacted the Healthcare Industry and will continue to impact it in the future.  Aside from the Missouri example already discussed, there is a lot of data showing that care coordination makes a difference for both patients and healthcare organizations.  Out of five care delivery innovations studied, a recent Health Affairs study showed that health IT and community health workers showed a cost savings of over $150 per beneficiary per quarter.  Community Health workers were described as "unlicensed employees who helped patients move through the healthcare system". In one example detailed in an Institute for Healthcare Improvement Care Coordination Whitepaper, an example of using care coordination to reduce hospitalizations in a population of 6,200 patients was estimated at about $1,000,000. 

Given these results, imagine how much more Care Coordination can accomplish in the future as a greater percentage of Healthcare organizations move towards Value Based Payment models.  There is a lot more to discuss on this topic, including how to get started, what tools a Care Coordinator requires, and some examples of the steps a Care Coordinator might take on behalf of their patient population.  Join me and my colleague, Melissa Lewis-Stoner, MSW, LCSW-C, for a webinar where we will continue this discussion and show how Relias Analytics is supporting the Care Coordinators of today already, and what innovations we have planned to take integrated care to the next level.

Register for the webinar