What makes for good care coordination?

Start by asking your patients

Ask a doctor if she thinks her hospital does a good job at care coordination — or an administrator or board member — and she’d probably say yes. She might admit to room for improvement, but in all likelihood, she would think she and her peers do a good job taking care of patients in and out of the acute care setting. But the reality is different, says quality guru and Harvard professor Lucian Leape, MD, chairman of an eponymous institute at the National Patient Safety Foundation.

"I teach a course on quality and safety in health care, and the first day, I ask the students to find a patient — any patient — with a serious medical problem who will talk to them about it, and interview them about their experience," he says. "It’s very worthwhile for the students. I read the essays and this year, three quarters of them had patients that reported serious care coordination problems. These are people with complex problems. And my take away is that this is endemic. These are patients from all over the country. It’s a huge problem, and yet most places think they coordinate care well."

A starting point

Leape says one of his colleagues has decided that talking to patients about their perception of care coordination is so vital, that she has developed a survey tool just for that.1 It’s currently being piloted. He says that hospitals can get a sense of patient views from other patient experience surveys, but those other surveys are not focused on how well patients think providers care for them across the continuum. Consider developing questions that would help you determine how your organization does in the eyes of patients.

There are some existing tools that offer a starting point, such as one created in Australia in 2003 (available at http://intqhc.oxfordjournals.org/content/15/4/309/T5.expansion.html).

Part of the problem is that the consequences of doing a bad job seem to fall on the patients, not providers. "Who sees it when you do not do a good job? And for the poorest or those in the worst health? Well they’re not really a vocal bunch are they?"

Another issue is that the position of "care coordinator" is not dignified by payers financially. "If you have a patient with more than two diagnoses, we need payers to pay for someone to actively coordinate their care," Leape says. "There is a ton of data that shows asthma patients, for example, have fewer emergency room visits and fewer hospitalizations when they have highly coordinated care. What we need is a certified care coordinator position whose time is billable and paid for by insurers."

Some organizations seem to do it well — Group Health in Seattle, for instance, and Cambridge Health Alliance. The latter provides safety net services for a "difficult" population of poorer, less healthy people in Massachusetts, Leape says. "But they have put a big emphasis on coordinating care for a long time."

Cambridge Health Alliance has certified five outpatient sites as patient-centered medical homes in the last 18 months, says David Osler, MD, MPH, senior vice president of ambulatory services for the organization in Somerville, MA. Most of the ambulatory sites for the organization are staffed with care coordinators, too. They have achieved some cost savings and some improved outcomes as a result, he says.

What he thinks would help would be a unified electronic medical record that both inpatient and outpatient providers can readily access. They have also had success by putting some patients on risk-based contracts. Perhaps the best thing a hospital can do is work with area providers to ensure every patient has ready access to outside primary care providers.

The playbook

"The hospital is like the quarterback in the football team," says Angel McGarrity-Davis, RN, a healthcare consultant based in Clearwater, FL. "The hospital must lead the other members on the team to perform their duties," she says. "They have to know what every person’s job is in the post-acute care arena. They must be able to relay to the various players what their responsibilities and accountabilities are. And they need to have input into the playbook."

That book would be the various clinical pathways and processes they use, as well as the evidence on which they are based.

Share that playbook throughout the healthcare community, she continues. Get out of the silos that isolate the various parts of the continuum — have joint training, for instance. Gather the team members to discuss what works and what doesn’t. "Working together is key," McGarrity-Davis says. "Get together with the skilled nursing facilities, long-term acute care hospitals, and home health agencies. Everyone should be on the same page for discharge planning, and the entire multidisciplinary team should be involved to follow up."

Most organizations will admit that such collaboration sounds like a great idea. Many may already do it.

But McGarrity-Davis adds another layer in that echoes a suggestion Leape makes: Get patients and their caregivers and/or families involved in the process, too. Have them work with the rest of the team to create forms that work, information that is understandable, and procedures that take the patient into account in the process.

Payers introduced penalties for unplanned readmissions for a reason, she says. "It’s not because hospitals are responsible for or the cause of the readmissions all by themselves. But they are the industry leader. So if the hospital seeks solutions, creates a plan, and says it should be done, then the rest of the continuum will follow suit."


1. Singer SJ, Friedberg MW, Kiang MV, Dunn T, and Kuhn DM. Development and Preliminary Validation of the Patient Perceptions of Integrated Care Survey Med Care Res Rev April 2013 70: 143-164


For more information on this topic, contact:

Lucian Leape, MD, Associate Professor, Harvard School of Public Health, Boston, MA. Telephone: (617) 576-6533. Email: leape@hsph.harvard.edu.

David Osler, MD, MPH, Senior Vice President of Ambulatory Services, Cambridge Health Alliance, Somerville, MA. Telephone: (617) 284-7000.

Angel McGarrity Davis, RN, CEO, AMD Healthcare Solutions, Clearwater, FL. Telephone: (855) 263-8255. n