Care coordination is only as successful as its underlying workflows and the technology that supports those workflows. Technology alone is not the driver or the answer. Rather, technology supporting carefully developed workflows and the teams that deliver care – this is the answer. More often than not, healthcare organizations create workflows around their technology and they find – often far too late – that the approach not only restricts innovation, but also has a negative effect on overall outcomes. Care coordination is not plug and play. It requires planning, collaboration with both internal and external stakeholders and partners, and a tremendous amount of flexibility.
Certainly, many of us have had a front-row seat to view this struggle. From small organizations to large, prestigious academic medical centers in big cities, this battle persists. There are a multitude of organizations doing great work; yet, getting arms around the big picture of programs and results continues to be challenging. Managing multiple programs to care for and engage a population can be especially problematic if visualization and coordination of these programs is lacking.
Relying on technology – most often a mix of homegrown and commercial applications – to create workflows for programs creates frustration, fragmentation and duplication. Lack of interoperability and thoughtfully structured workflows to tie together inpatient, clinic, home and outpatient efforts causes disjointed care even within the same health system.
Complicating matters, adopting an accountable care organization (ACO) model1, bundled payment or any other value-based model, without first developing workflows can be disastrous, leaving reimbursements and savings opportunities on the floor. I have seen this approach proliferate poor communication, overlaps and duplication in care, as well as wasted valuable resources.
Key Ingredients of a Successful Approach
In forcing workflows to fit with the technology, organizations spend money but are unable to achieve the desired results. Here is a structured approach to developing workflow-driven care coordination programs:
Gather all the stakeholders – internal and external – into a multifunction team
Without everyone in the room, you will never understand how data needs to flow between individuals and organizations. Make sure you have representatives from every role that will influence care coordination within your organization and in transitional settings such as home, post-acute facilities, and community resources.
Develop a roadmap
Rather than thinking only of the current state of the care coordination team and your current population, project further out. Do you plan to incorporate home health, behavioral health or community services in your care coordination strategy? If so, make sure you know which electronic health records are in use, as well as their workflows. Will you tap into community transportation services? Assure discussions include how booking, confirmation and feedback occur, and how mobile technology options may fit into the workflow. The roadmap is the view of where you see your care coordination model in the years to come – it will be the guide to building a nimble infrastructure that will grow with your population and your program.
Walk through scenarios and build test cases
Let your workflows drive your technology and what you need from it. Include handoffs between care settings, patient follow-ups, and close the loop with the care team across the continuum. Understand who is responsible for the patient in each scenario and how you make use of valuable resources. Assure you can track care coordination efforts, the impact of these efforts, and have an overall view from a management perspective of how your team is progressing toward goals.
Refrain from only chasing the dollar
Your workflows should represent the needs of your patient population and your ability to address those needs – not your ability to achieve a certain return. Map your workflows as such and make sure those workflows can scale as you expand your population profile and your payer partnerships.
Build a flexible environment
While you may start with a small segment of your population, you will grow. You will add in community partners, payer arrangements and populations whose needs will shift. You will need to make workflow adjustments accordingly. Your technology and your infrastructure must be able to support these changes. Continuous internal reflection to assure you are able to demonstrate you have the right players, at the right point in the care delivery process, performing the right activities scoped to their license, will mitigate misuse or overuse of key resources.
Determining and impacting the value of your care coordination activities requires visualization of the activities performed and who performs them, the outcomes and use of evidenced-based guidelines, and the ability to communicate and collaborate with all stakeholders. Care coordination can increase the chances of achieving greater care delivery efficiency with improved outcomes if you have the right people at the table to align metrics, develop, apply and track workflows, and apply the technology to maximize your workflow implementation.
Read other articles in this care coordination series:
5 Considerations for Successful Care Coordination & Population Health
Data Is Key to Recouping Care Delivery Control from Payers
Mitigating the Impact of Social Determinants on the Success of Clinical Care
- Centers for Medicare & Medicaid Services. Accountable Care Organizations. January 2015.