Care coordination success stories: Empower nurses, OpenNotes, involve patients

By Zack Budryk

Three organizations have had success with care coordination but with different approaches.

Geisinger Health System: Organization-wide learning strategies

A care coordination strategy that includes coordination between nurse navigators and community nurse case managers has helped Pennsylvania's Geisinger Health System cut emergency room visits and improve outcomes for heart failure patients.

In the past year, Geisinger has become a pioneer in care coordination and, despite its location in rural Pennsylvania, CEO David Feinberg, M.D., said the system's tactics can easily be applied to different settings. Strategies include coordinating and integrating care through organization-wide learning strategies that ensured the system was adopting technology such as electronic health records long before they were broadly popular within the industry. System leaders have also reached out to other systems and providers with similar goals for preventive care and population health, regardless of how far along they are in the process comparatively. 

Beth Israel Deaconess Hospital: OpenNotes

Other providers have gone even further in coordinating care by involving the patients in the process. At Boston's Beth Israel Deaconess Hospital, for example, the OB/GYN department has adopted the OpenNotes initiative, which allows patients to review their providers' notes for accuracy.

"Within OB/GYN we think that's incredibly valuable" for care coordination, Mary Herlihy (pictured right), M.D., an OB/GYN at Beth Israel Deaconess, told FierceHealthcare in an exclusive interview, "because it helps to reinforce the care that we're delivering."

Moreover, Herlihy said, such a step would be "very easily adaptable across all care settings," including larger systems, smaller providers and multidisciplinary groups. "Every discipline benefits from the patient seeing their record and having a better understanding of their health," she said. Indeed, research shows that initiatives such as OpenNotes can do wonders for doctor-patient communication, which is particularly vital considering poor communication is one of the primary obstacles to effective care coordination.

NewYork-Presbyterian Hospital: Manage patients for life

New York-Presbyterian Hospital decided to completely overhaul its care coordination and patient flow systems, according to Holly Meisner, New York-Presbyterian's vice president of patient access (pictured left).

As part of the overhaul, New York-Presbyterian "came up with a vision where our patients will be managed for life," Julie Mirkin, the hospital's vice president of care coordination, told FierceHealthcare.

To implement that level of care coordination, "we created an inpatient model, an outpatient model and a transitional care model and connected all of the three dots." The system's care coordination efforts included appointing a registered nurse care coordinator to meet with all patients face-to-face and do an initial assessment. Care coordination teams manage patients throughout the inpatient stay while also keeping in touch after discharge and conducting risk stratification to identify patients who stand the most chance of noncompliance with post-discharge instructions.

Care coordination success stories: Empower nurses, OpenNotes, involve patients