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Top Considerations for Care Coordination in Chronic Disease Management

Care coordination for chronic disease patients hinges on team-based care, communication, and seamless data sharing.

Care coordination is something of a holy grail in chronic disease management.

Without it, patients can’t connect the various—and often disparate—aspects of their care and achieve better outcomes.

Care coordination brings with it many benefits. Defined by the Agency for Healthcare Research and Quality (AHRQ), care coordination entails “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care.”

It should be emphasized that the patient is a key participant in care, most experts agree, and therefore must be looped into care coordination.

AHRQ said that care coordination could lead to better adherence to patient preferences as well as greater patient safety and administration of appropriate, timely, and effective care. In an industry increasingly embracing value-based reimbursement, care coordination is essential for eliminating duplicative services and ensuring patients get the best type of care at the right time.

But care coordination is a challenge, primarily because the United States healthcare industry is extremely fragmented. Studies show that care coordination duties often fall on patients and can be a serious detriment to the patient experience.

Effective care coordination strategies can reduce adverse events like hospital readmissions and duplicative testing or services and ideally cut costs. Healthcare organizations should consider the right care teams to assemble to fulfill care coordination efforts and ensure there are the right health IT interoperability and data-sharing provisions in place to support that team.

Team-Based Care

Because patients with chronic illness have specialized healthcare needs, it is likely they will need a team-based care approach.

According to the Institute for Healthcare Improvement (IHI), team-based care is “the provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, efficient, and equitable.”

In many cases, but not always, the primary care provider leads the care team or serves as the epicenter of patient care. But chronically ill patients are usually medically complex, so they need to meet with other specialists who then need to communicate with each other and the primary care provider.

Members of a chronically ill patient’s care team may include, but are not limited to:

  • Primary care providers/physicians
  • Advanced practice providers (nurse practitioners and physician assistants/associates)
  • Mental and behavioral healthcare specialists
  • Specialists relevant to a patient’s clinical condition
  • Dietitians or nutrition specialists
  • Community health workers

Team-based care works best when everyone is on the same page, according to the American Nurses Association (ANA).

“In applying the core principles for true collaboration, team members’ values must align,” ANA wrote in a brief on the topic, citing the Institutes of Medicine throughout. “Specific values reported include honesty, discipline, humility, creativity, and curiosity, and these values are interwoven through the principles of shared goals, clear roles, mutual trust, effective communication, and measureable processes and outcomes.”

To that end, members of the patient’s care team need access to healthcare communication and data-sharing technologies that will allow them to collaborate meaningfully on a patient’s care plan.

Provider Communication, Data Sharing

In order for all members of a patient’s care team to work together, they must be able to communicate and seamlessly share information about the patient.

If a patient with diabetes visits her endocrinologist, it is best for her primary care provider to have access to the information documented during that visit. The primary care provider can use that data to tailor her care plan going forward and stay looped in on any changes the endocrinologist made.

But that kind of data sharing is still out of reach for many healthcare providers.

In 2022, the Office of the National Coordinator for Health IT (ONC) reported that only 65 percent of office-based physicians had engaged in some form of data exchange, whether that be sending, receiving, or querying health information. Of those providers, 85 percent reported hiccups in accessing health information.

Without access to patient information, team-based care becomes difficult. Healthcare organizations should consider technologies that leverage FHIR-based APIs, as well as participation in streamlined health information exchanges (HIEs) to overcome these issues.

Moreover, it may be helpful to consider alternative platforms upon which members of the patient care team can “huddle” or discuss patient cases. Studies have shown that most providers see the EHR as the primary place to communicate with other members of the care team but that it is not conducive to meaningful conversations or mitigating conflicting opinions of care team members.

Some organizations have begun to co-locate their care teams, regardless of credentials or discipline, to facilitate in-person communication. Using other technologies, like video chats, may also help overcome some of the limitations introduced by EHR communication.

Care Transitions

Care transitions refer to the move from an acute facility, like an inpatient hospital stay or
ED admission, to a lower-acuity healthcare facility, like a skilled nursing facility (SNF) or rehab facility. Care transitions can also refer to the move back home.

As discussed above, the providers at the SNF or rehab facility need to be integrated as members of the care team. By using the EHR, data sharing, and other technologies to help these members huddle, providers should be able to ensure continuity of care for patients as they move from one facility to another.

As noted, care transitions also include moves from inpatient stays to the patient home. In these cases, tapping the right home health or hospital-at-home equipment is key, as is looping in any at-home providers and family caregivers.

But it’s not just about the continuity of care that’s important to care transitions; the patient experience is also important. Care transitions can be scary for patients and their family caregivers, so ensuring adequate patient education and support during the process will be key.

Studies have indicated that patient education and caregiver support can also result in better outcomes. One United Hospital Fund assessment showed that focusing on patient education resulted in better clinical outcomes. According to UHF, which looked particularly at transitions from SNFs to home, successful SNFs engaged in the following:

  • Better medication patient education
  • Better patient education about chronic disease management
  • Streamlined discharge planning to meet individual patient needs
  • Use of health IT and video technology to support patient education
  • Involvement of patients and caregivers in the discharge planning process

That high level of education, especially for a population who is chronically ill and will need to continue disease self-management when transitioning to a new facility or at home, has proven effective. One assessment showed that patient education can particularly reduce the risk of hospital readmissions, which is both a key clinical quality measure and a good way to improve patient quality of life.

Follow-Up Care

After an acute care episode, it is essential that patients access follow-up care. This is true of all acute care episodes, including acute care episodes for a chronic illness.

However, it can be challenging to get patients back into a facility after an episode. On the organizational side, there can be scheduling issues with follow-up care. Most healthcare organizations are struggling to meet patient demand, as made evident by extreme appointment wait times.

But follow-up care needs to be timely, throwing a wrench in the plans of practice administrators. Adjusting scheduling practices to leave room for last-minute follow-up appointments can be effective in overcoming these barriers.

Moreover, ensuring good communication between providers that are members of the same patient’s care team, as discussed above, can help streamline the transition from an acute episode into follow-up care. Good data sharing will also be essential for a follow-up appointment.

There are also patient-level barriers to follow-up care. One study showed that patients referred to follow-up care for certain medical screenings don’t end up scheduling because they don’t understand the necessity of the screening, indicating that patient education is failing. A separate study showed that healthcare costs keep some patients out of follow-up appointments.

Shared decision-making about follow-up care—when and where and how to get it—could help overcome these barriers.

This is also an area where patient navigators, who are non-clinical healthcare workers to help patients coordinate their own care, may be helpful.

Patient Navigation, SDOH

Patient navigation has emerged as a critical aspect of care coordination as patients make their way from primary care provider to specialist to acute care setting. Patients with complex medical need to manage a web of healthcare providers, not to mention social determinants of health, and patient navigators are increasingly being tapped to help direct patients through all of that.

In the clinical setting, patient navigators are in charge of helping patients schedule and make sense of their many medical appointments, find providers, and even understand medical bills. According to the Centers for Disease Control and Prevention (CDC), patient navigators “are staff members who work with patients to overcome barriers and understand the medical system,” the agency says on its website.

There is no set educational or credentialing requirement for patient navigators, leaving individual clinician offices or health systems to carve out a job description that meets the needs of their patient populations. In a sample job description, the CDC offers some example qualifications:

  • Minimum high school degree or some college education
  • Strong understanding of cultural competency with the target population
  • Bilingual (English/Spanish) preferred
  • Computer literacy desirable
  • Exposure to issues of death and dying

Notably, patient navigators have emerged as helpful for patients who are socially complex, meaning they screen positive for one or more social determinants of health. In addition to providing clinical patient navigation, these healthcare professionals can help patients navigate the social services available to help them manage SDOH.

For example, patient navigators may help patients obtain transportation services to their medical appointments or set them up with legal assistance through a medical legal partnership. These services are essential parts of care coordination as healthcare continues to understand the influence SDOH have on clinical outcomes.

Taking a Patient-Centered Approach

Patients are integral parts of the care team, most experts stress.

As such, it is essential for healthcare providers to tailor their care coordination approaches to a patient’s individual preference.

For example, ANA pointed out that some patients may not feel comfortable with a large care team and may prefer to keep a smaller circle of providers taking care of them.

“The most important team member is the patient,” the trade group said in its brief on the topic. “Not all patients are comfortable being much more active participants in health care decisions.”

A similar consideration should be made for care transitions. Patients may have different needs and views of where they would prefer to convalesce following an acute hospital stay, like using home-based care or admission into a nursing home or rehabilitation center.

Ultimately, engaging the patient in shared decision-making and incorporating them as a part of the clinical care team will be crucial to uncovering these preferences.

In addition to patient preferences, healthcare professionals need to make sure they practice cultural competency. Chronic disease management, and the care coordination that supports it, impacts nearly every facet of a patient’s life. To ensure patients actually engage in self-management strategies, it is key for providers to shape those strategies to a patient’s cultural and lifestyle needs.

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