Improving Patient Outcomes Through Care Coordination and Population Health Management

For the past 30 years, I’ve been deeply entrenched in healthcare and have had the great fortune of holding positions across the entire care continuum. Suffice it to say, the continuum most patients experience is far from perfect. How do we each use our sphere of influence to begin to improve outcomes throughout the healthcare ecosystem? Care coordination.

In 2016 the Comprehensive Primary Care Plus, Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and other public and private initiatives called for strong care coordination. Yet healthcare organizations have not been given the tools they need to develop successful, comprehensive care coordination approaches within a population health context to drive value-based care. Perhaps care coordination is not “one size fits all,” and organizations do not come to the table with the same level of expertise, technology or motivation.

More resources are devoted to healthcare per capita in the U.S. than in any other nation, according to the American Nurses Association; yet, our national healthcare system is often characterized by fragmented care, communication failures and unnecessary or redundant tests and services.1 On average, the cost of individuals with uncoordinated care is 75 percent higher than matched patients whose care was coordinated.1 If designed thoughtfully – by incorporating the five core components you’ll read about below – care coordination can improve the patient experience, improve health outcomes, and reduce wasteful spending – bringing us closer to achieving the goal Don Berwick and the Institute for Healthcare Improvement set for healthcare in this nation: the Triple Aim.2

These five steps lay the groundwork for a successful care coordination platform that everyone – no matter how sophisticated your approach – can build off of to achieve improved outcomes (beyond health), optimal patient experiences and cost efficiencies.

1. Institute a team-based approach.

Most physicians are used to operating in silos, yet value-based care is truly a team sport. A 2003 study in the American Journal of Public Health found that physicians would need 7.4 hours per working day to provide all the recommended services to a panel of 2,500 patients.3 If that was considered unrealistic when the study was published years ago, imagine the degree of reality in that statistic today, with the increased service demands and complexity within our system.

Physicians and healthcare organizations must look to care coordination as a mechanism to solve this problem. Successful care coordination begins by fostering collaboration at the office level and across the healthcare continuum, to ensure the appropriate level and depth of care is activated at the right time, in the right location and for the right patients. It is far more than making sure appointments are scheduled and kept; that lab results are received, interpreted and acted upon; and that specialty referrals are pursued as needed. It is about building and maintaining relationships with patients, their families or caregivers, hospitals, and the larger community. Patients benefit from having a single point of contact – such as a care manager or personal health nurse – to coordinate care across the boundaries of acute, primary, specialty, post-acute, long-term care, home care and clinic care. Someone who knows their story, their goals, and the barriers and idiosyncrasies that can keep them from achieving those goals. They want someone they can trust to help guide them on the path to improved or stable health. The care manager can be the cog on the wheel that each spoke ties back to – the quarterback or coach of the greater care team that goes beyond the four walls.

2. Know the details of your population to effectively manage the population’s health risk.

Population health is a critical focus of most new health reform initiatives. The Affordable Care Act has propelled change in both payment and care delivery reform, challenging our nation’s providers and health systems to provide optimal, coordinated care across the continuum in the most efficient way – and this is not as easy as it sounds. The incentives and penalties associated with our new healthcare landscape create both opportunity and peril. To maximize incentives in our new reimbursement models, organizations must understand the populations they serve and the current and future drivers of risk within those populations. For instance, a hospital or practice that serves an elderly demographic in a rural community is going to structure a care coordination approach differently than if it were serving a younger, urban demographic. Likewise, the engagement strategies and resources to accomplish that engagement will differ.

To fully visualize the health risks in your population, you must have the proper data systems, workflows and expertise to analyze that data. Today, most healthcare organizations contract with IT companies separate from consulting firms. Yet, a greater degree of success is achieved when your care coordination and care management strategies are built first based on your needs; do not try to “fit” the approach to the technology, but allow the approach to drive the design within your technology. The ideal approach involves partnering with a firm that can help evaluate, tailor and build the approach, as well as provide the technology and actionable data. That data not only needs to be actionable, but it should also lead to positive change.

Evaluating and building your care coordination approach includes making sure you have the right number and level of staff for your population needs. Assessing the current and predicted risk, cultural influences, access, etc., of your demographic may reveal the need for a new or differing skill set from your current care coordination structure. You may find you have to rebalance and restructure to address your population’s risk. Knowledge and successful management of your population will help prepare you for taking on the financial risk associated with the new payment models mentioned above.

3. Expand access and relationships to include more than just medical care.

Care has taken on a new meaning in the fee-for-value world. The care team now includes behavioral health, wellness, nutrition, and the impact of social determinants on individuals’ overall health. Prevention and treatment have moved beyond the hospital and office walls to pharmacies, urgent care clinics and retail centers. Our nation’s healthcare needs and demands are also driving the shift to value-based reimbursement. As healthcare consumers, we are all becoming increasingly engaged in what we are getting for the dollars we spend on our health. The landscape and population needs are ever-changing and your care coordination strategy needs to change with it.

Healthcare organizations, as a result, must think beyond extended hours to address access. A strategic, thoughtful approach to the drivers within your population and community may guide you to a multi-level model to coordinating care. This may include registered nurse care managers, licensed social workers, health coaches, or community health workers all working at the top of their license to enable patients to receive the full range of touch points they need to be successful in reaching their healthcare goals. Looking beyond the four walls includes tapping into the churches and schools in your community to create the relationships and foundation for true population health. Do you have nutrition, housing or transportation barriers affecting the population in your community? Who is the best resource within the community to close those gaps?

Robert Wood Johnson Partners has an integrated approach to care coordination focused on improving population health, the care experience and managing costs. They use collaboration within the care community to achieve these goals and extend beyond primary care.

4. Invest in individualized care.

While individualized care with care coordinators, health coaches and more may sound expensive, there are keys to assuring a return on investment. To see a return, organizations need to define and communicate their desired outcomes, and measure performance against those outcomes to assure that processes are continually adjusted for consistency with best practices.

The success of care coordination and individualized care also depends upon the focused work of the care coordination staff. Crucial to this success is the oversight to assure time is spent on the right interventions, for the right people and for the right amount of time. Our focus and oversight support your pursuit of balanced outcomes in quality, cost and satisfaction.

A focus on meeting people where they are and attaching the right resource to the right need can help keep a high-risk patient from multiple emergency department visits. Care coordination can ensure that a stable diabetic with a new diagnosis of hypertension knows the impact of that new diagnosis and what he or she can do day-to-day – or with whom to connect – to manage this new disease combination. Strategic care coordination can also engage communities to interact on a regular basis with primary care clinicians and the medical community, driving necessary screenings and education, and potentially avoiding the onset of costly diseases. It can drive efforts not only to the highest risk or highest utilizers of care, but to those emerging-risk patients for whom we can mitigate disease progression or development with early engagement aimed at prevention and education. Think big! Imagine coordinating care for your population in a different way: How many lives could you touch to proactively effect change?

5. Prepare for the shift to new payment models.

Today, many payers try to own or dictate care management. The medical community must be positioned back in the driver’s seat for this shift to value to succeed. Overcoming the wariness of engaging in value-based care because of payment mechanisms, the level of effort to change or cumbersome reporting is simply not a justification for inaction. The Department of Health and Human Services has set the goal to have 30 percent of Medicare payments in alternative payment models by the end of 2016 (this target was achieved in March) and 50 percent by the end of 2018.4

Some may think the move to value will bring in less money and they may find the number of metrics for various payers staggering. It can seem extremely burdensome for a physician who just wants to take care of patients. Caring for people is what this is all about. MACRA and the Merit-Based Incentive Payment System (MIPS) will certainly accelerate the timeline to value-based reimbursement and highly coordinated care over the next few years.

Our nation needs each of us to focus on building healthier communities – whether you are a physician, a nurse or a school principal. No longer is the gold standard a proposed model that features a care team whose goal is providing non-duplicative, continuous, comprehensive and timely care. Population health requires broad, multidisciplinary models to move beyond case management to other aspects of life including health behaviors, social and economic factors and physical environments.

If one looks through the lens of progress, this new landscape is driving us back to the team-based coordinated care we learned in nursing school – with a different approach to selecting the best team to field. The sooner you begin evaluating the efficacy of your care coordination strategy as it relates to the needs and details of your population, the sooner you begin to prepare for the shift to value.

Remember, this is only one key component of the preparatory effort – but one that will help set the stage for success in the new world of healthcare.


  1. American Nurses Association. The Value of Nursing Care Coordination, p. 1; p. 5. June 2012.
  2. Institute for Healthcare Improvement. The IHI Triple Aim. May 2008.
  3. U.S. National Library of Medicine. Primary Care: Is There Enough Time for Prevention? Abstract. April 2003.
  4. Centers for Medicare & Medicaid Services. Better Care, Smarter Spending, Healthier People: Paying Providers for Value, Not Volume. Rewarding Value: Where We Are Going. January 2015.
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