Recent decades have seen increasing complexity of patient pathways especially for patients with chronic diseases and co-morbidities. This has led to information gaps and silos, with implications for safety, access, and outcomes. This article examines examples of how care coordination can fail and how health systems, governments and entrepreneurs are approaching the problem of care coordination.
Clinical care coordination is the process of organising and coordinating healthcare and related services for patients, particularly those with complex medical conditions. It involves ensuring that all necessary medical services, tests and treatments are provided in a timely and efficient manner ensuring that patients receive the right care at the right time, in the right place, and from the right provider.
Effective clinical care coordination is therefore crucial for improving patient outcomes and reducing healthcare costs. It requires a multidisciplinary approach, from doctors, nurses, allied health professionals, social workers and others.
The author is an emergency medicine doctor with senior management experience in the acute sector. This article builds on his direct experience of problems of care coordination as both a physician, a relative and carer, as well as a healthcare leader.
A 45-year-old man with crushing central chest pain is admitted to the emergency room with suspected MI. The patient's blood sugar level of 29 mmol/l suggests that type 2 diabetes is a likely precipitating factor. The patient’s relatives report that his HbA1c was measured at 6% 3 years ago but had not been repeated, as required by guidelines.
Discussion: The prevalence of T2 diabetes is growing exponentially worldwide and presents a significant public health problem in many countries as they develop and age. Who was responsible for ensuring that this test was repeated? Had the patient moved under the care of different care organisation? How the patient was made aware of the original test result.
A 29-year-old woman, 23 weeks into her second pregnancy is admitted to the ED with collapse and sepsis. She has a positive ‘flu test. Her baby was born with extreme prematurity, and she spent two weeks in ICU. Her family remember that she was offered a ‘flu vaccine but failed to attend her appointment.
Discussion: Pregnant women have poorer outcomes with influenza, as do their babies. No adverse effect at the population level has been observed from the vaccine. Who knew that this woman had failed to attend her vaccination appointment? Whose responsibility was it to follow up?
A 75-year-old bed- and chair-bound man is re-admitted to hospital with sepsis caused by a worsening of a large sacral bed sore. He had been discharged three weeks earlier following an admission for a fall. The dressing had not been changed while he was at home.
Discussion: Frail elderly patients are at risk of deterioration following discharge for a number of reasons. Discharge instructions can be confusing or absent in many cases. Community nursing colleagues and families are often not aware of the care plan put in place by the discharging hospital. Who was responsible for managing the pressure ulcer?
1) Lack of visibility of information across boundaries
All patients, but especially those suffering from chronic diseases and significant co-morbidities, often see multiple providers across different settings, which makes their care fragmented and disconnected.
The core challenge is that the information visible to one team may not be visible to another. These information gaps can lead to lapses of care, such as the cases given above, but also to additional ‘care’ such as repeated tests or unnecessary visits to practitioners.
2) Lack of accountability of action
As emphasised in the examples above, much of the problem of clinical care coordination comes from a lack of clarity about who is to do what, by when. We are all commonly aware that without individual accountability (such as when we use ‘all’ in meeting notes) there is ultimately a loss of action.
Most electronic medical records, if they record actions at all, store these either as appointments or as lists, with little regard for who is responsible.
3) Complexity of care pathways
As care becomes more complex, more interrelated actions are required to effect good outcomes. For example, the pathway for a fractured neck of femur when printed in ‘booklet form’ may run to several tens of pages, involving actions over many days of care from preparation for surgery, catheter removal, mobilisation and more.
4) A lack of patient involvement
Many patients want to be involved in their care but are either excluded or find it difficult to understand what is needed. When highly activated patients or their families are involved, this can help reduce errors and omissions. For the frail or elderly, or patients who live alone, this can be challenging.
Poor care coordination can have a number of negative consequences for patients, including:
• Delayed or missed care: Patients may not receive the care they need in a timely manner, or they may miss appointments altogether.
• Medication errors: Patients may be prescribed the wrong medications, or they may take medications incorrectly.
• Duplication of services: Patients may take the same tests or receive the same procedures multiple times.
• Hospital readmissions: Patients with chronic diseases are more likely to be readmitted to the hospital if their care is not coordinated effectively.
• Higher healthcare costs: Poor care coordination can lead to higher healthcare costs due to unnecessary duplication of services and hospital readmissions.
There are a number of different approaches to care coordination. Some common approaches include:
• Care teams: Care teams are groups of providers who work together to coordinate care for a patient. Care teams may include doctors, nurses, social workers, pharmacists and other healthcare professionals.
• Case management: Case managers are healthcare professionals who work with patients and their families to coordinate care. Case managers can help patients navigate the healthcare system, schedule appointments and communicate with providers.
• Health information technology (HIT): HIT can be used to improve care coordination by providing providers with access to patient information, such as medical records and medication lists. HIT can also be used to track patient progress and communicate between providers.
Health systems, governments and entrepreneurs are all taking steps to address the challenge of care coordination.
Health systems are developing new care models, such as patient-centred medical homes and accountable care organisations that focus on coordinating care for patients with chronic diseases. Governments are investing in HIT and other technologies to improve care coordination. Entrepreneurs are developing new products and services to help providers coordinate care more effectively.
The future of care coordination is likely to be shaped by a number of trends, including:
• The rise of value-based care: Value-based care is a healthcare delivery model that focuses on improving patient outcomes while reducing costs. Care coordination is essential for value-based care to be successful.
• The increasing use of technology: Technology will play an increasingly important role in care coordination. For example, electronic health records (EHRs) can be used to share patient information between providers. Telehealth can be used to provide care to patients in remote locations. And wearable devices can be used to collect data about patients' health and activity levels.
• The shift to population health management: Population health management is an approach to healthcare that focuses on improving the health of entire populations, rather than individual patients. Care coordination is essential for population health management to be successful.
To ensure that patients receive the best possible care, health systems, governments and entrepreneurs are all taking steps to address this challenge. By working together, these approaches can improve care coordination and deliver better outcomes for patients.
One important issue is the role of the patient. Patients are increasingly being recognised as active partners in their own care coordination. Patients can play a role in their own care coordination by:
• Communicating their needs and goals to their providers.
• Organising their medical records.
• Keeping track of their appointments and medications.
• Asking questions and advocating for themselves.
Another important issue is the use of data and analytics to improve care coordination. Data and analytics can be used to identify patients who are at risk of poor outcomes, such as hospital readmission. This information can then be used to develop interventions to improve care coordination for these patients.
In addition to the things mentioned above, there are a number of other emerging technologies and approaches that have the potential to transform care coordination in the future. These include:
• Artificial intelligence (AI): AI can be used to develop tools that can help providers identify patients who are at risk of poor outcomes and develop and implement interventions to improve care coordination for these patients.
• Blockchain: Blockchain is a distributed ledger technology that can be used to securely share patient information between providers and organisations.
• Patient portals: Patient portals are online platforms that allow patients to access their medical records, schedule appointments and communicate with their providers.
These technologies and approaches have the potential to make care coordination more efficient, effective and patient-centred.
While there are many opportunities to improve care coordination, there are also a number of challenges that need to be addressed. These challenges include:
• Data silos: Patient information is often siloed in different EHR systems and other databases. This makes it difficult for providers to access the information they need to coordinate care effectively.
• Lack of interoperability: EHR systems and other healthcare IT systems often do not communicate with each other effectively. This makes it difficult to share patient information between providers and organisations.
• Patient engagement: It is important to involve patients in their own care coordination. However, many patients are not comfortable using technology or engaging with the healthcare system.
Despite the challenges, there is a growing recognition of the importance of care coordination. Health systems, governments and entrepreneurs are all investing in new technologies and approaches to improve care coordination. By working together, we can create a healthcare system where all patients receive the coordinated care they need to achieve their best possible health outcomes.