Care Coordination – A Solution Towards Operational and Patient Journey Improvement Nikhil Taurani Context of the Proposal The client is head care coordinator of Montefiore medical center, and the purpose of this research is to identify challenges, best practices, and possible interventions associated with care coordination About Care Coordination AHRQ Definition – Care coordination involves deliberate organization of patient care activities and sharing of information among all the participants concerned with a patient's care to achieve safer and more effective care. Implications of failure in delivery of coordinated care Increased medical errors and delays Research Questions 1 What are the current challenges in the US healthcare system with care coordination? 2 What are the best practices in care coordination in different countries and hospitals? 3 What are possible interventions that can be implemented in current status quo? Importance Increased complexity in care coordination due to evolution of modern medicine Accounts for $27.2 to $78.2 Bn wastage per year Increased hospital readmission and decreased health outcomes Increased bottlenecking in patient and transition care Challenges in efficient implementation of coordinated care in the US Several clinicians and healthcare professionals face challenges in coordination, information collection and exchange in the US healthcare system Coordination Professional Territorialism: Permission to access information restricted due to inability of stakeholders to cooperate Technological Participation between Stakeholders: Follow ups and referral lag due to lack of engagement between patient, families and healthcare professionals Lack of Information or resources: Missing patient data due to errors in documentation, and lack of resources due to high medical expenditure Information Interoperability: Deferring EHR records across hospitals and states causing hindrances in information exchange, especially with social workers IT Infrastructure: Absence of a National Health record system, in addition to inability to collect data in realtime which increases lag in information exchange and interpretation Best practices in care coordination in different countries and Best practices across each challenge was analyzed across different healthcare systems and hospitals to hospitals identify efficient interventions that could be implemented in current status quo Challenges Example Description • Professional Territorialism Stakeholders participation Lack of information or resources Gesundes Kinzigtal Health pathway for elderly patients - France Sweden – One bundle payment system • • • • • • Information Interoperability: UPMC FOR YOU – community team • • IT Infrastructure National Healthcare system, Estonia • Formulated networks with hundreds of providers, nursing homes, ambulatory care, pharmacies and health community. Outcome – decreased cost per patient by 233$, improved coordination, and decreased length of stay in hospitals Inter-disciplinary primary care team which plans and coordinates activities; a support platform that provides a single point of access to local health and social services for clinicians, care givers and patients. Outcome – reduction in cost of acute care, and improved continuity of primary care. One bundle system, where specific chronic diseases are purchased, billed as a single product or service, specifically for diabetes. Outcome – Decreased specialist care, patient and provider experience improved to 90% rating, improved cholesterol and Blood pressure clinical outcome Team based approach where care is provided in multiple settings. Utilization of telehealth to communicate, and monitor patient health. Outcome – Increased engagement between stakeholders, and similar engagement rates between telehealth and in-person visits Government of Estonia implemented a system wide health information system, with secured access across all disciplines and levels of the system Outcome – 90% have health documented in the National system, improved information continuity, improved communication and decision Initial steps organizations can adopt under current status quo Identifying specific target groups, formulating network with different stakeholders, incentivizing collaboration and, including support groups in the decision-making process can enhance care coordination Recommendations Identify population and specific groups to enroll in care coordination program, especially highrisk individuals. Integrate digital information systems and revamp IT infrastructure to facilitate enhanced Information Interoperability, predictive analysis, and real time data collection Focus efforts on inpatient discharge and transition care, through team-based approach along the care pathway Formulate networks by contracts or relationship building, especially with stakeholders outside the organizations network to improve coordination and management of resources and patients Support members through engagement and inclusion of care givers, social workers, and families to improve adherence to care coordination programs Introduce payment methods that focus efforts on specific groups and incentivizes collaboration between different healthcare stakeholders In Conclusion 1 Care coordination involves deliberately organizing patient care activities and sharing information is essential for patient care, improved clinical outcomes and efficiency of an organization. 2 Information exchange and technological support prove as a challenge in the USA, which makes it difficult for efficient care models to be implemented. 3 Best practices show that formulating networks, targeting specific population groups, shared decision making, and utilization of digital information systems improves care coordination. 4 Montefiore Medical Center should focus on utilizing tele health, formalize networks, and focus on specific target groups with high risk to efficiently allocate resources and improve their care coordinating efforts. 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