Improve Engagement and outcomes for patient populations

Improve Patient Care With Our Care Management & RPM Solutions

Everything You Need to Know About Care Coordination Models 

by | Jul 26, 2023

Care coordination models are instrumental in enhancing the quality, scope, and efficiency of healthcare delivery. By adopting a patient-centered approach, these models ensure seamless and well-integrated care across settings and among providers. 

What Are Care Coordination Models? 

Care coordination models are structured methods that ensure patients receive the most appropriate care, at the right time, and in the right setting. By streamlining communication and collaboration among healthcare providers involved in a patient’s care, these models are poised to improve patient outcomes, enhance patient experience, and reduce healthcare costs.  

Who Benefits from Coordinated Care Models? 

With an eye on efficiency and more productive care collaboration, there are many ways patients and providers benefit from effective care models. 

  • Better care outcomes – Proactive care management and regular follow-ups reduce the risk of complications and hospitalizations 
  • Enhanced patient experience and empowerment – Cutting down on repeated medical history and tests as information is readily available to all providers involved in the patient’s care, plus patients are more likely to adhere to plans where they have a role in decision-making and goal setting 
  • Cost savings – Avoid unnecessary hospitalizations, emergency room visits, and redundant tests, leading to cost savings for both patients and healthcare systems 
  • Reduced errors – Improved communication and information exchange among healthcare providers reduce the risks of medical errors or adverse events 
  • Enhanced networking in healthcare – Collaboration helps providers work more efficiently and effectively as a team 
  • Optimal communication – Through up to the minute correspondence between providers about a patient’s care and an organized process for patient progress, teams can work effectively and efficiently 
  • Proactive response to SDOH – Having ready solutions to a patient’s personal set of social determinants of health needs results in better care outcomes 

Reduced fragmentation in healthcare benefits all and coordinated care models serve as the blueprint for better engagement and improved efficiency. 

The Core Elements of Care Coordination Models 

To better understand models for coordinated care, you should know the mechanisms behind them. Below is the anatomy of a coordinated care model. 

  • The multidisciplinary team – Healthcare professionals, including physicians, nurses, social workers, pharmacists, care managers, community health workers, dieticians, and other specialists work together in planning, executing, and evaluating a patient’s care plan 
  • Communication and sharing of information – The seamless exchange of information between care entities is fundamental for care coordination, especially concerning electronic health records (EHRs), and often includes regular care team “huddles” 
  • Care plan development – Based on the patient’s individual needs and goals, the care plan outlines the specific interventions, treatments, and services per the patient’s conditions and while clearly indicating the role of each provider in the care plan 
  • Activating patient engagement – Care coordination cannot be successful without patient engagement where patients are encouraged to actively participate in decision-making, self-management, and care plan adherence 
  • Transitions of care – Effective handoffs and communication during transitions help prevent medical errors and preventable readmissions such as hospital to home or home to skilled nursing facilities 

Aside from good business sense, there is support for better coordinated care from administrative entities. Government and private payers understand the benefits of collaboration in care as well. 

The Influence of Public Policy for Broad Adoption of Coordinated Care 

Growing support for coordinated care underscores its transformative potential in shaping a more efficient, patient-centric, and cost-effective healthcare landscape. Administrative initiatives for coordinated care include: 

  • Standardization of health information exchange protocols and promotion of interoperability among different healthcare systems to ensure seamless sharing of patient data 
  • Reimbursement models that incentivize care coordination and value-based care drive healthcare organizations to adopt more patient-centered approaches 
  • Expanded adoption of technology through incentives that facilitates care coordination, such as telehealth platforms and EHR systems 
  • Enhanced training and education on care coordination practices can improve understanding and implementation of these models 
  • Establishment of policies that address social determinants of health, recognizing their impact on patient outcomes and the importance of incorporating community-based resources into care coordination efforts 

What Are the Different Types of Care Coordination Models? 

From the complexity of healthcare follows many kinds of care coordination models. Common ones include: 

  • Patient-Centered Medical Home (PCMH) – A designated primary care provider oversees the patient’s care and collaborates with specialists and community resources 
  • Accountable Care Organization (ACO) – Groups of healthcare providers, hospitals, and clinicians who work together to coordinate care for a defined population of patients and are accountable for the quality and cost of care provided to their patients 
  • Care Transitions Intervention (CTI) – Manages the coordination of care during transitions including recruitment of an advocate who helps patients understand their care plan and manage their health post-discharge from a care facility, usually a hospital 
  • Chronic Care Model (CCM) – To manage chronic conditions effectively, evidence-based guidelines, self-management support, care coordination, and community resources come together to enhance care for patients with long-term challenges 
  • Bundled Payment Model – A single payment is made to cover all services related to a specific episode of care, such as joint replacement or cardiac surgery to, in effect, incentivize care coordination to improve outcomes while reducing costs 
  • Community-Based Care Coordination – Arrangement of community resources, such as social services, housing assistance, and transportation, to address social determinants of health and improve overall well-being 
  • Program of All-Inclusive Care for the Elderly (PACE) Model – Integrates care for the elderly who are on both Medicaid and Medicare 
  • Wraparound Model – Arranges services for children with significant or complex needs and their families 
  • Community HUB Model – A centralized registry of at-risk patients to be matched with services through a network of care coordination agencies 
  • Community Health Worker Model – Advocates connect those in need to health, human, and social services organizations 
  • Nurse-Family Partnership Model – First-time mothers with low incomes are connected to support resources that promote healthy pregnancies, child development, and economic self-sufficiency 
  • Health Homes Model – Patients with chronic conditions and mental or behavioral health problems, who are also on Medicaid/Medicare receive help with healthcare and social services 
  • Mobile Unit Model – Provides access to health and human services by travelling to rural areas that are underserved 
  • Supportive Housing Model – Arranging services for individuals experiencing homelessness 

Knowing what care coordination entities are out there, providers can gain the additional support they need to serve special-case patients within the population.  

What Are the Challenges and Barriers to Effective Care Coordination? 

The ideal is to have healthcare that coordinates in an optimal way, but there are certain hurdles that stand in the way of progress. Here are common reasons that effective care coordination is not as prevalent as it could be: 

  • Fragmentation in healthcare systems – Providers and organizations operating independently leading to fragmented care and communication gaps 
  • Insufficient interoperability – Different electronic health record systems that do not properly communicate or effectively share patient information are a hindrance to care collaboration 
  • Resource constraints – Resource limitations (financial and human) pose challenges in implementing and sustaining initiatives in care coordination  
  • Lack of buy-in – Some healthcare providers are reluctant to adopt new care coordination practices, especially when it requires changes in workflow or roles 
  • Social determinants of health – Economic factors such as housing instability and lack of access to transportation can impact the ability of patients to engage in care coordination efforts 
  • Concerns over privacy and data security – Without robust privacy and security measures in place, care coordination cannot operate properly 

As we seek solutions to these challenges, there is hope that care coordination will become universal within healthcare. 

Innovations that Support Care Coordination 

As healthcare systems continue to evolve, several innovations and best practices will emerge to enhance care coordination further. Enhancements to consider are: 

  • Telehealth or remote monitoring – Healthcare providers can monitor patients’ conditions remotely and provide virtual consultations with the help of technology 
  • Data analytics and Artificial Intelligence (AI) – Automation can process vast amounts of patient data to identify patterns and trends, enabling proactive interventions and personalized care plans 
  • Patient Engagement – Patients can actively participate and adhere to care plans through interactive patient portals, mobile apps, and wearable devices 
  • Care navigators and coaches – Advocates assist patients in understanding their care plans, connecting them to community resources, and supporting them throughout their care journey 
  • Team huddles – To promote better communication and coordination, regular collaborative meetings can ensure that everyone is informed about the patient’s progress and needs 
  • Partnering with community organizations and social services – Reaching out to community resources helps address social determinants of health, such as access to nutritious food, safe housing, and transportation, which can significantly impact patients’ health outcomes 

Summary: What You Need to Know About Care Coordination Models 

Coordinated care models are a solution to many challenges and barriers to healthcare. Both patients and providers can benefit from a structure and processes that promote well-integrated care. This includes establishment of teams, interoperability, effective care planning, patient engagement, and successful care transitions from hospitals. 

With so many care models currently in place that can support providers in search of solutions for their patients, better care outcomes are within reach. By leveraging the tools, technology, techniques, and established networks, you can work with other entities to provide effective and cost-conscious solutions for your patient population. 

Doing Our Part to Promote Coordinated Care Through Technology and Process Solutions 

The concept of care coordination and its many benefits make it a very appealing prospect, but many healthcare providers find that there are hinderances to their goals to be better collaborated and integrated. At Medical Advantage, we seek to find solutions around these obstacles so that your organization and patients can reap all the rewards of coordinated care. 

If your organization aspires to level up to coordinated care, we are here to help every step of the way. At Medical Advantage, our teams work together to make your technology – such as the EHR – work to its full potential. We also promote collaboration in healthcare through our Accountable Care Organization (ACO). Reach out to us today to learn more about how consulting can make your organization better coordinated and more efficient in care delivery. 

Author

  • Mary Ellen Cross

    Mary Ellen Cross is the Manager of CIPA's Cost Team, where she leads her team in supporting practices to reduce healthcare costs. The Cost Team provides practice-specific data, identifies opportunities, and suggests actionable interventions for cost reduction. In addition, they s...

Related Posts

Doctor in a meeting

Exploring athenaOne®: EHR Features That Streamline Medical Practice Management

With a significant focus on integrating medical practices with technology, athenaOne® offers top-of-the-line features that streamline the documentation process while improving patient care. From authorization management, to pre encounter prep and patient encounters, athenahealth offers a full suite of solutions to improve clinical efficiency and patient care quality. To get the most from athenaOne® you […]
Read More
medical professionals

Everything You Need to Know About Care Coordination Models 

Care coordination models are instrumental in enhancing the quality, scope, and efficiency of healthcare delivery. By adopting a patient-centered approach, these models ensure seamless and well-integrated care across settings and among providers.  What Are Care Coordination Models?  Care coordination models are structured methods that ensure patients receive the most appropriate care, at the right time, […]
Read More

Talk to a Care Management Expert Today


Improve Engagement and outcomes for patient populations

Improve Patient Care With Our Care Management & RPM Solutions

Medical Advantage - TDC Group