Coordinated care is a crucial part of the healthcare process that cannot be ignored. According to a survey of more than 1000 elderly patients, 34% of them relied upon family members to help coordinate their care while 35% had no assistance with care. To make matters more complex, these patients often have multiple chronic conditions that require multiple healthcare providers, making it even more essential that care is coordinated. This lack of coordination can lead to care discontinuity with dire consequences that include complications and mortality.
The problem and what needs to be addressed
According to another survey from the 2016 Commonwealth Fund Survey of High-Need Patients, several issues were brought to light that revolve around the lack of adequate coordinated care processes which, if implemented well, would be able to maintain health status throughout a continuum of care. The survey raises red flags in areas of readmissions, healthcare delivery efficiency, delays in care, and inadequate access to services and support—all of which are weak points that can be seen as opportunities to improve care coordination, and consequently, the quality of care for patients.
The solution: multidisciplinary coordination
The key to successfully addressing the red flags mentioned above is to take on a multidisciplinary approach to healthcare. Care coordination needs to be viewed as an effort that spans the entire care cycle of the patient, from initial hospital admission to post-acute care, and thus requires an extensive healthcare team to accomplish this. Without a comprehensive team, only certain aspects of patient health are addressed while others are ignored, and the successfully treated patient that comes out of the hospital without proper follow-up or support may enter into readmission. Improvements in coordination should focus on optimizing teamwork and increasing communication at those points of care where there is a greater risk for care discontinuity (i.e. transitions to different care environments).
This “dream team” of care deliverers involve multiple people who are specialized in certain areas of the healthcare delivery process. This includes those who work in the hospital to get the patient out of an acute state (i.e. hospital physicians, specialists, nurses, medical scribes) and those working with the patient outside of the hospital to support them in maintaining a stable health condition (i.e. primary care physicians, physiotherapists, counselors or case managers). This large team of people with various skills allows for tasks to be delegated to those who are most qualified to perform it, ensuring optimal performance in each sector of care delivery.
However, in order for a team to achieve the greatest level of coordination, this is not enough; there needs to be a way to bridge the tasks of each area of care through precise communication. This communication is necessary to create smooth transitions between the various levels of patient care and ensure that the patient is being optimally treated and monitored throughout the entire long-term health episode. Medical scribes are crucial bridges to this communication between hospital and post-acute care because their accurate documentation provides a record of care history that makes the job easier for the post-acute care provider. Case managers are also another crucial element to the care coordination process. By checking up on patients to make sure that they are adhering to medical instructions and attending follow-up visits, they are not only actively maintaining efficient care delivery, but they are also an additional source of psychological and social support to patients.
As the saying goes, “No man is an island.” Individual healthcare professionals cannot go at it alone to keep their patients healthy in the long-term and need the coordinated assistance from others to make the care process as smooth, efficient, and effective as possible.
Patients who are paired with Care Navigators report feeling less anxiety, and an increased ability to self-manage their conditions between visits. And providers report increased job satisfaction from improved efficiency, and knowing their patients have access to care teams, and strategic support.
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