Care coordination challenges: Poor communication, tracking patient populations

By Zack Budryk

So what's holding organizations back from effective care coordination? In many cases, it's one of the farthest-reaching problems in the healthcare industry: poor communication.

"Healthcare systems are disjointed," Christina Dempsey (pictured right), chief nursing officer at Press Ganey, told FierceHealthcare. "Patients often don't know why they're being referred or how to make appointments or what to do with their care, [while] specialists don't always get info from primary care physicians as to why patients are being referred to them and then primary care providers don't get information from the specialists after the visit."

Newer, more advanced healthcare settings such as retail clinics, standalone emergency rooms and telehealth, also have potential to coordinate care by keeping patients out of the hospital, Dempsey added. "As long as those entities are communicating with the pre- and intra-hospital and post-acute environment they can be an integral part of the whole care across the continuum."

In many cases, the increased focus on technological issues can complicate the communication necessary for effective care coordination, according to Julie Mirkin, vice president of care coordination at New York-Presbyterian Hospital. "In healthcare we tend to find technology solutions to problems without really examining how they interrelate with one another," she said, noting that "multiple systems… were created and leveraged to improve similar processes but don't talk to each other."

Another big challenge is keeping track of information for the entire patient population rather than those who are coming to you, according to Mark L. Wagar, president of Heritage Medical Systems. 

"You can have a great intervention system for people who come to see you for congestive heart failure," he said, "but if you're trying to take care of 50,000 seniors in an accountable care organization across two counties, and 5,000 or 10,000 of them have some development of congestive heart failure, the 2,000 or 3,000 who may be so sick they come to see you know, you take great care of them but you really could avoid a lot of events for [the rest] if you're able to engage with them, help educate them about the things that will most help them."

This, he added, is why the advent of value-based care will likely be a boon to care coordination, as these models enable interventions that seek out patients before an incident requiring hospitalization. "Information in the clinician's hand about the patient" is the biggest piece of the puzzle, he said.

Despite these barriers, Mirkin said she has high hopes for the future of care coordination, due in large part to the rapid transition to value-based care models. This emphasis on value, she said, is "forcing hospitals to really think about the long-term delivery of care," which in turn provides incentives to providers to think about what's best for the patient after discharge. "This is a really exciting time to be part of driving and developing and creating the future of care coordination," she said.

Care coordination challenges: Poor communication, tracking patient populations