4 steps for effective care coordination

As healthcare leaders prepare their hospitals or hospital systems for sweeping changes, such as the shift to value-based care and increased readmission penalties, they must also improve care coordination. Patient satisfaction, the bottom line and care quality all improve when care coordination programs are effective, and there are several steps to ensure this, according to Hospitals & Health Networks.

When designing care coordination programs, healthcare executives should make sure to include several steps, writes Richard Royer, CEO of Columbia, Missouri-based healthcare consulting firm Primaris, including:

Assign clear responsibilities: Communication issues, in addition to hurting coordination efforts and increasing readmissions, often confuse both patients and specialists about the reasoning behind referrals. To improve accountability and continuity of care, healthcare leaders should define responsibilities for processes such as communicating with other physicians, following up on test results, and sharing hospitalized patients' background information and findings. They also must determine when responsibilities should be transferred from one provider to another.

Strengthen referral systems: Patients' chances of being referred to a specialist have almost doubled since 2009, writes Royer, and to get them the best possible care, it's vital that hospitals track referrals, especially for conditions like cancer for which early diagnosis and treatment is key. To ensure a smooth referral process, leaders must develop an internal tracking system, establish referral protocols, inform primary care physicians in the event of inappropriate referrals and ensure transparency between physicians after the visit.

Strengthen relationships between all parties: Part of care coordination is making sure hospitals, primary care providers, long-term care providers and specialists all understand their respective roles. To ensure this, Royer recommends clear expectations and guidelines for information-sharing, written documentation of all agreements and a standard communication protocol that keeps everyone on the same page.

Prepare patients to manage their own care: Clinicians must make sure patients understand post-discharge instructions, which has helped hospitals such as Beth Israel Deaconess Medical Center in Boston dramatically slash readmissions. That means providing patients with a discharge checklist, making sure staff follow up with patients after their referral visits, and intervening if a patient fails to keep a referral appointment.

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