Care Coordination: The Key to Holistic, Equitable, and Value-Based Healthcare
Care coordination, a proven strategy for enhancing outcomes for chronic disease patients, has yet to gain wider implementation. The intersection of technological advancements, policy changes, and economic influences has now positioned it for mainstream adoption.
What is Care Coordination?
The term “care coordination” is often used interchangeably with care management, but there is an important difference.
Let's begin by outlining a definition of care coordination. The Agency for Healthcare Research and Quality (AHRQ) defines it as "the deliberate synchronization of patient care activities and the sharing of information among all participants involved in a patient's care to achieve safer and more effective outcomes”(1). This definition underscores the collaborative nature of care coordination as it envisions seamless engagement with any individual or service that can tangibly support patient well-being. Care coordination happens "between the white spaces" along a care pathway, acting as a bridge between the many organizations and people that provide services to the patient. This relationship is summarized in Figure 1, with care coordination depicted as the connecting element surrounding the patient.
Figure 1. Care coordination enables a care plan and connects the many possible service providers, including those outside of medical care. All participants have visibility to the patient’s needs and preferences. This figure is adapted from AHRQ (3).
Why Emphasize Care Coordination Now?
There are three important factors that advance care coordination today as a key to unlocking better healthcare delivery.
1) Social Determinants of Health (SDOH) have become an undeniable, integral part of health optimization. SDOH include access to safe housing, nutritious food, transportation, social networks, and many more factors impacting the whole person. Disregarding SDOH leads to ineffective interventions, rising costs, and the perpetuation of disparities (5).
2) Addressing SDOH is essential to achieving health equity. By improving the conditions in which people live, work, and age, we can reduce the disproportionate health burdens faced by marginalized communities. Only by tackling these root causes can we create a society where everyone has a fair and just opportunity to achieve optimal health and wellbeing.
3) Healthcare in the U.S. is in an active state of transition towards a value-based model. Incentivizing patient-centered outcomes based on quality metrics, overall experience, and individual needs drives systemic reprioritization within both payer and provider organizations. This trend breaks the problematic fee-for-service mold and creates a fertile environment for effective care coordination.
These converging forces, propelled by an increase in market competitiveness and empowered patients as healthcare consumers, have irrevocably transformed the concept of optimal healthcare delivery.
What Makes Care Coordination Possible Today?
There are three enabling technologies and accompanying regulations that make care coordination more possible today than ever before.
1) The 21st Century Cures Act's data interoperability requirements foster unprecedented data liquidity between the historically siloed healthcare ecosystem (6) . This level of interoperability, via a common FHIR-based API, is the crucial backbone for successful care coordination when gathering and disseminating information from healthcare providers and payers. The Trusted Exchange Framework and Common Agreement (TEFCA), also required under the Cures Act, is just now becoming a reality promises to enable broad data sharing.
2) AI tools are steadily maturing, increasingly capable of automating the routine, labor-intensive tasks inherent in care coordination efforts. While nacent, this promises to relieve burden on human team members through enhanced automation, fostering better utilization of their judgment and interpersonal skills for direct patient interaction.
3) Robust, searchable platforms for accessing and matching social support services are now available. Service aggregators like Findhelp, Unite Us, and HealthBridge empower care coordinators with practical non-medical community based resources tailored to a patient's specific needs.
Summary
Care coordination offers a strategy towards the pinnacle of healthcare: patient-centered, equitable, and outcomes driven by value over volume. As technology continues to evolve and policies supporting this model become more robust, the prospect of future success appears increasingly possible for patients, providers, and the healthcare system as a whole.
