By Melinda Young, Author


Two Midwestern health systems exemplify the emerging new strategy of coordinating integrated care systems to improve patient care and reduce hospital and ED readmissions.

  • Hospital case managers collaborate with other hospital providers, as well as with community case managers and providers, to develop care plans.
  • Hospitals develop relationships with skilled nursing facilities, home health agencies, and primary care providers.
  • In one strategy, a health system identifies patients at risk of frequent readmissions for a coordinated care team to target them with comprehensive, individualized care plans.

Health system leaders nationwide are beginning to break down care silos and coordinate integrated care systems. In some models, hospital case managers work with their community and payer case management peers, and everyone participates in a care team with a targeted care coordination plan.

For example, a Michigan healthcare system has spent more than a year integrating all care coordination activities across its region with the goal of aligning with a strategic, integrated plan. An Ohio health system also is coordinating care to reduce ED and hospital readmissions.

Hospitals, ambulatory sites, physician offices, skilled nursing facilities (SNFs), and home health are all part of the Trinity Health strategic plan, says Mary Beth Pace, RN, BSN, MBA, vice president of care management at Trinity Health in Livonia, MI.

“Integrated care coordination means we’re wrapping our arms around our patients,” Pace says. “We’re integrating with organizations where we have them and creating relationships with SNFs and home health when we don’t own that.”

Breaking Down Silos

Taking a patient-focused approach, an Ohio health system is identifying patients at risk of frequent readmissions to manage them with a coordinated care team. The team helps patients improve their health by using comprehensive, individualized care plans.

“We have individual cases where we’ve improved patients’ readmissions and connected them to ambulatory resources,” says Colleen Royer, RN, MSN, CCM, senior director for care management at Cleveland Clinic Health Systems Eastern Region Hospitals.

“Our patient philosophy is put patients first and help them stay out of the hospital, stay healthy, and manage their chronic diseases in the best setting,” Royer says. “This breaks down barriers between silos and inpatient and outpatient and the community hospital. It improves dialogue among all of those resources in the community, keeping patients in the right setting for their needs.”

The three pillars of the Trinity Health strategic plan are community health, well-being, and episodic care.

“We make sure all care coordinators in all of those buckets are reporting to a single clinical executive,” Pace says.

There can be case management handoffs. Providers share case information via an electronic medical record, when this is possible. Not all electronic records can be shared between different health organizations, but technology is improving and making interoperability possible, Pace says.

The goal is for acute care coordinators to be able to read notes from community providers. When all providers are within one accountable care organization (ACO), sharing data is simpler, she notes.

“The patients we have more difficulty with are those patients that show up on our doorstep and are assigned to another ACO in our area,” Pace explains.

Focus on Optimal Communication

Optimal care requires communication between healthcare organizations, patients and families, and payers about patients’ care plans.

The Cleveland Clinic Health Systems case managers reach out to insurance company case managers to share their patient care plans and make sure everyone is working toward the same goal, Royer says. (See story on Cleveland Clinic’s care coordination in this issue.)

“We’re trying to negotiate for the patient, collect resources, and navigate throughout the healthcare system,” she says.

Care coordination works best when there is optimal communication.

“The ultimate goal is for care coordinators to communicate with each other and keep the plan,” Pace says.

The process can start in the hospital or ED. Hospital case managers do everything they can to make sure patients transition to the appropriate level of care, says Colleen Fitzgerald, MSN, CCM, ACM-RN, director, system care management, Trinity Health.

“Patients in acute care facilities are managed by acute care coordinators, and they follow patients in the hospital,” she says.

“We do interprofessional rounds daily, on all nursing units, to discuss patient care,” Fitzgerald adds. “Physicians, nurses, case managers, therapists, and social workers attend the rounds and discuss the patients for one to two minutes each, discussing care transition plans for each patient.”

Making sure the entire team is involved with the patient’s care takes a lot of work, she notes.

Care Coordinators Help With Handoffs

Transition handovers help patients in the next site of care. The integrated care coordination system can provide a good handoff process to the community, Fitzgerald says.

“We make sure we’re handing over patients to the next site of care, even for those not in the model,” she says. “We make sure we’re doing good communication to ensure the patient’s care is in place for any patient that goes out of our hospital to the next level of care.”

In the acute care environment, the care coordinator is responsible for all admitted patients, Pace says.

“If a patient in the emergency department is stabilized and needs medical follow-up, the emergency room knows they are followed by a care coordinator in the community, which helps with transitioning them back to the community,” she explains. “If there is no care coordinator, then the emergency department might keep them in the hospital if they are not comfortable with medical follow-up.”

Patients are handed off to community care coordinators using handover tools, including one that Fitzgerald helped create, called the Handover Process SBAR. (See overview of Trinity Health’s integrated care coordination tool in this issue.)

Each piece of the tool represents a part of what the handover should include. SBAR stands for situation, background, assessment, and recommendation/request.