The New Standard of Care Coordination

By November 9, 2021 November 30th, 2021 No Comments
ICS value-based care experts dissect how care coordination is one of the most critical strategies that can transform the health system and what the new standard of care coordination should look like.

9 Care Coordination Strategies to Reduce Rehospitalizations

A historically fragmented U.S. healthcare system paired with a population crippled by chronic disease and rising risk has resulted in poor patient experiences and higher than sustainable provider costs.

November 9, 2021

More specifically, the disconnect has led to unnecessary rehospitalizations.

The problem is widespread. In fiscal year 2022, the Centers for Medicare & Medicaid Service (CMS) will penalize 82% of the 3,046 hospitals evaluated under the 10th year of the Hospital Readmissions Reduction Program. The 2,499 hospitals that reportedly had too many Medicare patients readmitted within 30 days could face as much as a 3% pay cut for each Medicare patient stay. 

“The good news is that 2022 marks a 1% improvement from the previous report,” says Brian Fuller, CEO of Integrated Care Solutions (ICS). “Though this is not even close to a mediocre benchmark. Readmissions are largely preventable with reliable care coordination and targeted interventions designed to directly address key contributing factors.” 

According to the Institute of Medicine, care coordination is considered a critical strategy with the potential to improve the American health care system’s “effectiveness, safety, and efficiency.”

With the shift to transformative value-based care models, care coordination is unequivocally necessary. As of late, 500-plus accountable care organizations (ACOs) and 50-plus Direct Contracting Entities (DCEs) participate in capitated risk—a commitment to improving quality care while reducing total cost-of-care. If done correctly, participants can increase profit margins significantly. However, unnecessary readmissions due to poor quality care coordination can quickly impact the bottom line. For value-based care organizations, financial success relies on the highest standards of care. Period.

Below, ICS experts and partners discuss nine strategies that define a new standard of care coordination that is proven to dial back readmissions and significantly lower total cost-of-care. 

Airtight Patient Transitions
“From a background in ACO management and building Clinically Integrated Networks in numerous markets, I know transitioning patients appropriately is one of the most impactful things we can do. Ask yourself, ‘Where would our performance be if we were the best transition organization in the region, state, country?’ Unfortunately, it’s an area that 90% of the country struggles to perform. With that in mind, successful care coordination should show airtight results transitioning patients from hospital to skilled nursing facilities, to home health, to home with self-care—anywhere throughout the post-acute care continuum. Micromanagement of patients, robust KPIs for nursing staff, and alignment with patients’ physician networks are the gold standard we should all strive to achieve. 
Robert Millette, MBA, FACHE, Vice President for Delivery Innovation

Data-Informed Care 
“To be successful in value-based arrangements, a system provider group has to be facile with real-time, sophisticated data analytics. We’ve certainly benefited from that with [care coordination] partnerships … to use the data streams that are available to us to weave together clinical, operational, and financial data to drive success in these programs.”
—Dr. Nihar Desai, Medical Director for Value Innovation, Yale New Haven Health

Empowering PCPs
“Primary Care Provider burnout is real and continues through the ebbs and flows of the COVID-19 pandemic. Care coordination that positions nurses as the extension of PCPs ensures any gap in care is avoided. Nurses pick up where PCPs can’t stretch any further. They are hyper-focused on the patient care plan, communication, and coordination which provides peace of mind for PCPs that there are always eyes on the patient.”
—Andrea Rizik, MS, BSN, RN, Vice President of Clinical Integration and Clinical Operations

Patient-Centered Communication
“Communicating with patients needs to be considered a critical component of care coordination—from supporting caregivers to prioritizing mental health to speaking early and often with patients with serious illness so they can accept the care that meets their goals. Patients need an advocate—a ‘quarterback’—ready to lead on their behalf. When care coordination puts the patient first through strong communication, it most certainly leads to improved patient experiences and reduced readmissions.”
—Brian Fuller, CEO

Innovative Technology for Customized Care
“Next-level care coordination will be about advancing our use of data and technology throughout the patient’s care journey to drive more customized patient engagement. By doing this, care coordinators will have the right information at the right time to more precisely hone in on patient needs, in addition to their existing and developing risk factors. It will also enable stretched clinical teams to focus on those patients at not just higher, but more specific risk categories. We can use technology to move from one-size-fits-most to many-sizes-fit-many. For example, just because 50 patients share a set of similar health characteristics, this doesn’t necessarily mean each should share the same care plan. With technology, care coordination can improve cohort identification and customized care planning, which will lead to both higher quality outcomes for patients and more efficient service delivery outcomes.”
—Kristen Croke, Director of Product Management 

Identifying High- and Rising-Risk Patients
“Forecasting a patient’s health is as important as managing current chronically ill patients. Successful care coordination requires nurses to identify early signs of rising risk, extend PCP care plans to the home of patients, or manage them proactively as they encounter additional healthcare needs. It is also key to engage patients and caregivers in their own active identification of rising risk symptoms with clear, direct, disease-specific patient educational materials. Being trained to detect signs of complications for everyone involved in the patient’s care including the patient is the difference between a patient’s rehospitalization and remaining in place.”
—Andrea Rizik, MS, BSN, RN, Vice President of Clinical Integration and Clinical Operations

Connecting to Local Services
“A care coordination team should be well connected to community resources that can address anything from mental health to health equity gaps to offer the full spectrum of care needs. Not all care is medical. Care coordination that just stops after the contracted care timeframe isn’t prioritizing patient experience. Setting up the patient for success in their community is just as important as clinical care.”
—Andrea Rizik, MS, BSN, RN, Vice President of Clinical Integration and Clinical Operations

Translating Complex Policy Into Action
“Organizations struggle to coordinate care because they don’t understand the very complex and unique clinical, operational, financial, and reimbursement environment. They may understand the clinical, but they don’t understand what operationally makes it work or not work. They may understand the operations, but they don’t understand the reimbursement environment that’s driving decisions. Even if you were to learn it all today, you can’t apply it tomorrow because the regulatory environment constantly changes. It’s hard for value-based organizations to be effective in coordinating care in that evolving environment without additional support from a knowledgeable care coordination partner.”
—Brian Fuller, CEO

Shared Risk Model
“Progressive care coordination companies are sharing risk with their partners. If CMS requires ‘value’ participants to commit to risk, care coordination should share in the risk. Together, it’s a commitment to patients—to keep them safe and where they want to be—and almost always, that’s not in the hospital. When you take care of the patient, the financial savings will follow.”
—Ajay Singh, Vice President of Strategic Growth

The ICS Difference: High-Tech, High-Touch Approach to Care
At ICS, standard care coordination isn’t good enough. We want to drive the “new standard.” Our patient-centric solutions prioritize the patient experience while maximizing efficiencies and generating total cost-of-care savings for our “value” partners. By combining innovative technology and robust data with compassionate and knowledgeable care, we ensure the best outcomes for patients and customers.

Watch Video: ​​3 Ways ICS Supports Value-Based Care Organizations

ICS helps organizations transform from fee-for-service to value-based care and delivers ongoing care coordination, consulting, and expertise in data-driven processes necessary to achieve quality care and financial success. If you are an ACO, DCE, hospital, or payer in need of a partner with expertise in value-based care and proven results working with risk-bearing organizations, contact ICS today for a free consultation.


Education and Communications are Key to Successful Patient Transitions