Many people still think of Care Coordination as nurses or social workers connecting with patients over the phone to manage a condition, such as heart failure, or to prevent an acute event, such as a readmission. As most patients are increasingly used to online access for most aspects of their lives, Care Coordination 2.0 has become a different concept where technology enables patients and families to self-serve while maximally engaged and where health providers collaborate together around the patient to ensure best outcomes and maximum efficiency. This is where the right action is taken at the right time based on the right information.

‍
Leading modern health organizations, both fee for service and those focused on Integrated Care, Accountable Care and Value Based Care, are adopting Care Coordination solutions to automate workflows, optimize their health team’s time management and increase patient and family satisfaction. If well designed, the benefit of using technology is that it also has the potential to generate data to enable population health management, predictive analytics and constant improvement.

‍
There are now known best practices when considering a Care Coordination Platform and what would be the best type for your health organization. In this post, we provide an overview of Care Coordination Platforms, how they contribute to a patient’s care journey, and list some key questions to evaluate if the platform chosen is a good fit for you and your patients.

• How do Care Coordination Platforms contribute to patient success?
• What are the different types of Care Coordination Platforms?
• What questions should I ask when considering Care Coordination Platforms?
• What does success look like?

How do Care Coordination Platforms contribute to patient success?

The activities of Care Coordination have proven benefits particularly for patients at moments of transition (diagnosis, admission, transfer and discharge) and especially if they have multiple health conditions. It has also been well documented that a technology backbone is required to enable care coordination efforts to be sustained and offered at scale. It can be otherwise overwhelming for multiple healthcare providers and family members to coordinate and manage all the action items necessary to support the patient, all while staying informed about the patient’s status on a frequent basis.

In response, Care Coordination Platforms have been created as a way for organizations, patients and their support teams to better plan the patient care journey, stay connected and optimize the execution of their personalized care plans. By leveraging technology that seeks to integrate the various forms of treatment a patient may have, the Care Coordination Platform acts as a “one stop shop” for all the information that is related to their clinical journey.

Through the use of the Care Coordination Platform, patients with complex medical needs or chronic conditions are able to have all their information consolidated onto one reference point, allowing for easy access to the different care plans and resources they may require along their healthcare journey. This reduces time spent navigating multiple platforms and websites, and decreases the likelihood of overlapping or conflicting information. Having a singular platform where patients and their support teams can stay informed and involved is a key component for prioritizing their health goals and achieving patient success.

The opposite of Care Coordination is fragmented care: when health care providers act from appointment to appointment, don’t plan the care journey, don’t communicate effectively with each other and the patient and family. All of this results in wasted time, energy and resources and poor satisfaction, and at worse, massive issues with care quality and safety.

Depending on their design, Care Coordination Platforms can also contribute to patient success in other ways:

• Improved communication: Care Coordination Platforms can facilitate better communication and collaboration among healthcare providers, patients, and caregivers. This can help ensure that everyone involved in a patient's care is on the same page and has access to the same information.

• Increased patient engagement: Care Coordination Platforms can provide patients with tools and resources to actively participate in their own care, such as patient portals, mobile health apps, and remote monitoring devices. This can help patients stay informed about their health and take a more proactive approach to managing their conditions.

• Better care coordination: Care Coordination Platforms can help healthcare providers manage and coordinate care for patients with complex medical conditions or multiple chronic conditions. This can help ensure that patients receive the right care at the right time from the right providers.
  
  
• Enhanced population health management: Care Coordination Platforms can help healthcare providers track and manage the health of entire patient populations, identify high-risk patients, and implement preventive care measures. This can help improve outcomes for entire patient populations, not just individual patients.

Overall, Care Coordination Platforms can help improve the quality of care, increase patient satisfaction, and reduce healthcare costs by reducing duplicative or unnecessary services, preventing hospital readmissions, and improving care transitions.

What are the different types of Care Coordination Platforms? 

Care Coordination Platforms are very different in what they offer in terms of functionality, ease of adoption and use, and what information is captured. Some of their functionality overlaps with a number of other health care software, the same way as different healthcare professions overlap in some of their skills: 

• Electronic Health Record (EHR) Systems: These are computerized systems that store patient health records and many now allow healthcare providers to share patient information with patients through Patient Portals or Digital Front Doors.

• Health Information Exchange (HIE) Platforms: These platforms enable healthcare providers to securely share patient health information with each other across different healthcare organizations and systems.

• Care Management Platforms: These platforms help healthcare providers to manage and coordinate care for patients with a single complex medical condition, and usually without patient and family engagement.

• Population Health Management Platforms: These platforms help healthcare providers track and manage the health of entire patient populations, identify high-risk patients, and implement preventive care measures.

• Telehealth Platforms: These platforms enable healthcare providers to deliver care to patients remotely, such as through virtual visits and teleconsultations.
  

• Patient Engagement Tools: Various mobile health apps, and remote monitoring devices provide patients with tools and resources to actively participate in their own care usually around a given medical condition.

Each of these platforms can help improve care coordination and communication among healthcare providers, patients, and caregivers as one aspect of the puzzle or as an element of what they were designed to do.

The main difference with a true Care Coordination Platform is that it’s primary function is designed to capture all the key aspects needed to deliver on care coordination best practices from the perspective of all the key stakeholders, which is needed in order to deliver on it’s proven potential:

• Patient/Family Perspective: Care coordination are the activities that help ensure that the patient's needs and preferences for health care and information sharing across people, functions, and sites are met and that patients and families are optimally engaged.
  

• Health Care Professionals Perspective: Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the healthcare system.
  

• System Decision-Makers Perspective: Care coordination is the responsibility of any system of care to deliberately integrate personnel, information, and other resources needed to carry out all required patient care activities between and among care participants (including the patient and informal caregivers) in order to facilitate the appropriate and efficient delivery of health care services both within and across systems.

See more about this in the Agency for Healthcare Research and Quality (AHRQ)’s overview here.

What questions should I ask when considering Care Coordination Platforms?

When selecting a Care Coordination Platform to be implemented in your organization, here are the 15 best practice key questions to consider and evaluate if they are the right fit for you. 

Connectivity

1. Does the platform connect across ecosystems? Specifically, can a community group, two different hospitals on two different platforms, and a primary care practice communicate, share information, and actively participate in the patient’s care plan?
2. How is multimorbidity handled? Can the platform manage multiple conditions concurrently in a single person-centred experience?
3. Can patients invite family and caregivers? How many?
4. Can the system manage population health as a group? Can it apply actions to entire populations and subpopulations at scale?

Integrations & data

5. Does the system integrate with EHRs? Can it pull data from third-party applications, or only their own proprietary devices?
6. Is the sharing of information with EHRs push and pull? Or is it push only? Or pull only?
7. What other app integrations are in place?
8. What analytics and insights about trends are available? Is there predictive AI? Beyond surfacing a recommended action, does it give the tools to act on the recommendation?

Getting started

9. Does the system offer user-level access and permissions?
10. Can users set up their own content/workflows without code?
11. Can users customize per physician and personalize per patient?
12. What is the estimated time to train? What training support is offered?
13. How long does it take to configure and get started? Do you do a co-design session? What other support is offered?

Specialization

14. Does the platform support complex chronic conditions? How many diseases are supported?
15. Can it support discharge and transition planning? From acute to community care?

Download a complete list of these evaluation questions.

What does success look like?

Adopting an effective Care Coordination Platform enables the organization to deliver on the proven potential of Care Coordination on the Quintuple Aim:  improved outcomes, increased satisfaction, better health equity, enhanced clinician well-being at optimized use of resources.

• Patient/Family: Feel confident and supported, know what needs to be done and when, don’t have to repeat their information, don’t fall between the cracks, get better faster and can live their life instead of worrying about their health.
  

• Healthcare Professionals: Have access to all the information that they need, function at the top of their license, close gaps in care, prevent care safety issues, monitor patients progress, collaborate with others and engage their patients the way they prefer,  implement quality improvement concepts and new ideas in their practice faster.
  

• System Decision-Makers Perspective: Ensure that their teams provide timely and appropriate care, efficient and effective patient-centered care while improving their bottom line, guarantee that data sharing is done according to required rules and regulations, and access real-time data to identify areas for improvement. 

We are here to help

By carefully considering these points prior to adopting a new Care Coordination Platform, this will ensure that the time and energy taken for its implementation will positively impact and truly meet the needs of your organization and your patients.

‍
Book a demo today with Careteam at info@getcareteam.com to see how our Care Coordination Platform could work for you. If we are not the right fit for you, we will recommend other platforms that may meet your needs.