Good Care Coordination vs. GREAT Care Coordination

By May 2, 2022 May 18th, 2022 No Comments
Green graphic that says good care coordination versus great care coordination

9 Standards that Ensure GREAT Patient Care Coordination

Among value-based care organizations, patient care coordination is a star player in the high-stakes risk-management game. 

May 2, 2022

Among value-based care organizations, patient care coordination is a star player in the high-stakes risk-management game. 

The Centers for Medicare & Medicaid Services (CMS) incentivize risk-bearing organizations like Accountable Care Organizations (ACOs) and Direct Contracting Entities (DCEs) to provide the best care at the lowest cost. To succeed, these organizations often seek out expert partners who specialize in care coordination services or attempt to develop programs and solutions “in-house.” Either way, “care coordination” has many meanings for health systems and organizations. 

In general, care coordination is designed “to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people and that this information is used to guide the delivery of safe, appropriate, and effective care.”

Due to this loose definition, leaders at organizations are left to demystify what care coordination is and how to best put it into practice.

When done correctly, patient care coordination can increase profit margins significantly for value-based care (VBC) organizations. However, poor quality care coordination can lead to unnecessary readmissions that can quickly impact the bottom line. For VBC organizations, financial success relies on the highest standards of care. Period.


But, the reality is that patient care coordination strategies and standards are not created equal. Some programs lean into technology and remove clinicians from the picture. Some offer no technology and rely on their high-touch oversight. Some engage social workers when clinical expertise is actually required. 

Truth: Care coordination tactics, strategies, and realities differ.

So what do you need to know to vet a good care coordination program or company versus a GREAT one? Integrated Care Solutions’ Vice President of Clinical Integration and Clinical Operations, Andrea Rizik, MS, BSN, RN, runs through nine examples of typical care coordination practices and alternatives that define GREAT care coordination.

Care coordination is NOT taking 7-10 days to schedule a PCP appointment

Great care coordination has a Registered Nurse touch base within 24 hours of admission (discharge) or care transition and ensures the scheduling of a home or offsite visit with the patient’s primary care doctor, or specialist if appropriate.

“Especially for the most chronically ill, highest-risk population, a week can seem like an eternity. Checking in on a patient and ensuring follow-up care with their doctor is an easy way to prevent a trip to the hospital.”

Care coordination is NOT one and done

Great care coordination doesn’t stop with one pass. Through repetition, patients better absorb important information. 

“For example, at discharge, our nurses provide comprehensive medication reconciliation and ensure all teachings—with repeat demonstrations—are completed and shared with ICS and post-discharge providers. This may include, repeat demonstration of PEG tube care, blood sugar testing and insulin administration, foley care, colostomy care, hoyer lift training, skin protection, wound care, transfer, elevation, and ambulation supervision or assistance.”

Care coordination is NOT one call after hospital discharge

Great care coordination is having a Registered Nurse touch base every three days (at minimum).

“At ICS, we like to say, ‘A lot can happen in 72 hours,’ which is why we provide a high-touch approach to supporting our patients and making sure they stay safe and comfortable at all times.”

Care coordination is NOT calling patients just to say hi

Great care coordination is going beyond a phone-call check-in and following a patient throughout their episode of care

“20% of beneficiaries have an episode of care in an average benefit year which amounts to 40% of the total cost of care for the entire population. Analog methods aren’t enough. Along with our high-touch approach, we add a ‘high-tech’ layer called Care+—a task and workload management software that helps care teams communicate and clinicians improve patient care.

Care coordination is NOT waiting till the end of an episode to discharge

Great care coordination starts on day 1 of admission.

“It’s a mistake for hospitals or skilled-nursing facilities to feel like they don’t have to address discharge planning until patients are ‘ready to go home.’ Our mantra is that ‘discharge planning starts upon admission.’ Every aspect of the patient’s needs—physical, social, and emotional—are taken into account through the transition.”

Care coordination is NOT 8-5, Monday to Friday

Great care coordination is access to care support 24/7.

“We provide 24/7 Ask ICS FirstTM support to give our patients and their loved ones peace of mind that we are always available to answer any and all questions. Breaking down that barrier of communication is essential for patients and their providers to know problems won’t escalate.”

Care coordination is NOT avoiding tough conversations about end-of-life

Great care coordination is embracing conversations about advance care planning.

“Advance care planning is often not discussed—what the patient’s code status is or what the patient’s desires are. We can be the agents of conversation by identifying those patients who may have had redundant readmissions and may be approaching end-of-life. We also have the specialty to handle these conversations sensitively for patients and families, and the ability to communicate their needs to care providers.”

Care coordination is NOT only clinical oversight

Great care coordination offers patients a team of clinical and community-based experts.

“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.”

Care coordination is NOT covering the basics

Great care coordination is comprehensive, providing patients and partners with clinical care, navigating regulations and policy, understanding reimbursement models, and offering to share risk.  

“Organizations struggle to coordinate care because they don’t understand the very complex and unique clinical, operational, financial, and reimbursement environment. ICS offers value because we have a track record of navigating these complex systems to best serve patients and relieve our partners of added costs and stress. We are also so confident in our results for partners that we take on their risk as part of our payment model.”

If you are an ACO or ACO REACH applicant 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.

ICS accelerates the transformation to value-based care for ACOs, providers, and payers, delivering ongoing care coordination, consulting, and expertise in data-driven processes necessary to achieve quality care and financial success.


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