The Care Coordination Triangle

Successful three-way care coordination offers new insight and increased revenues

Healthcare coordination that connects three critical points on the patient’s care “map” is proving to be a source of unplanned revenue and streamlined expenses for many physician practices. Like the stability that comes from three legs of a stool, care collaboration that connects the primary care physician (PCP), the emergency department physician and social programs providers is proving to benefit patient outcomes, reduce unnecessary emergency department visits and improve care satisfaction. What PCPs had not anticipated until implementing a new care model, is that highly coordinated care communication across an expanded team increases practice revenue, decreases lapsed patient follow-up and streamlines practice engagement allowing for more efficient care delivery.

Navigating EHR Systems is Pivotal

For today’s healthcare team, care coordination starts with electronic health record coordination. Improved care coordination must address how EHRs share care data to create a more holistic record. Stretched across networks of acute, post-acute and primary care facilities, EHRs are too often siloed and lack a common “key” to connect them.

Mapping patient records across EHRs facilitates the creation of a longitudinal care record and is the first step in breaking down communication and coordination barriers. Once patient data can be unified across care recording platforms, true coordination can begin. Through effective patient mapping, EHRs can transform from “recording” platforms to “integration” platforms.

Integration in Action

Collaboration between hospitals and physician practices is central to reducing unnecessary emergency department visits and is important in providing the care data PCPs need to plan, validate and adjust treatment plans. The relay of real-time admit, discharge or transfer (ADT) records from sending hospitals to PCPs, alerting physicians that patients were recently seen in an area hospital, begins to build a necessary communication bridge in the care ecosystem.

Coordination Across a Triangle of Care

Navigating a patient’s journey that may include a physician practice, hospital and out-patient treatment program presents challenges. Even in an era of electronic care tracking, patient “matching” across an ecosystem of care facilities and programs requires interoperable HIT systems, notifications across care teams and patient participation. PCPs can’t follow-up on ED visits that they don’t know about, and even though admit, discharge, transfer (ADT) notification exists, matching alerts to patient records across a network of PCPs can be challenging.

A physician network in Michigan breaks down communication barriers to increase care visibility and, in the process, increases revenues for their practices.

Michigan’s Northern Physician Organization (NPO) built a care “bridge” with the help of eMedApps for over 50 active practices. This bridge unlocks silos of patient information increasing visibility across the network. Email notifications are sent to the primary care physicians by Direct Trust, a provider-to-provider direct exchange, either into the EMR or to a designated account through the NPO Health Information Systems Program (HISP). The provider is alerted days before a discharge summary would normally arrive from a hospital.

Extending the Care Conversation to Social Services Teams

Augmenting the care conversation includes coordination with social service providers such as mental health agencies, alcohol and tobacco cessation programs, and other sub-acute, rehabilitation and wellness programs. PCPs not only recommend social and wellness programs as part of their overall care plan, they can also follow-up on patient participation and progress.

NPO recognized the benefit of deeper patient engagement facilitated by technology. NPO now brings social workers into the care continuum including utilization of services and promotion of deeper out-patient engagement and monitoring. Currently, three community mental health agencies receive notifications helping social workers identify and reduce the risk of treating drug-seeking patients.

Coordination Offers Unexpected Benefits

By matching patients with their complete care record, regardless of where care is delivered, PCPs can assemble a more comprehensive view of care and tailor treatment programs accordingly. Physician practices can follow-up and schedule patients for clinic visits, reducing the waste of frequent and unnecessary emergency department visits. By routing patients to the appropriate care facility, practices often see an increase in revenue and a corresponding increase in patient satisfaction with care delivery.

Physician practices, like NPO, employing or utilizing automated care coordination recognize even greater benefits including:

  • Automatic and rapid curation and sharing of complete patient information
  • Increases in patient satisfaction and confidence in care provided
  • Improvement in patient tracking and management allowing practices to run more efficiently
  • Improvement in post-discharge follow-up, meeting Meaningful Use quality measures
  • Decreases in non-emergent ED use, eliminating waste
  • Greater sharing of patient records through networked HIEs and physician practices reducing duplication of unnecessary or redundant procedures

Powering a Conversation about Care

Unlocking and unifying patient records across a continuum of care offers benefits to a broad network of providers, patients, and social services teams. Connecting the care journey patients travel is essential to reducing costs, improving outcomes and helping care delivery practices optimize resources and increase revenues.

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