Care Coordination: A Renewed Focus

Improving patient experience, outcomes and affordability


Care coordination has always been imperative in the healthcare industry, serving as a foundational center of medical practice for years. However, in the new healthcare environment, the topic is getting renewed attention as part of a widespread effort to help health systems better manage high-risk patients. Across the board, systems are looking to improve outcomes, increase patient satisfaction and experience and lower the cost of care. With a comprehensive care coordination plan in place, patients, providers and payers benefit.

Defining Care Coordination

The Institute of Medicine identifies care coordination as a key strategy that has the potential to improve the effectiveness, safety and efficiency of the American health care system. According to the Agency for Healthcare Research and Quality (AHRQ), the main goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. The agency says this is first achieved by understanding and knowing what those needs and preferences are, communicating them at the right time to the right people and using this knowledge to guide the delivery of safe, appropriate and effective care. Some of the key components of care coordination, include:

  • Patient-centered model of care
  • Communication and knowledge-sharing
  • Teamwork and accountability
  • Care and medication management
  • Health information technology
  • Care transitions, monitoring and follow up
  • Resource alignment with patient and population needs

Achieving Safe, Appropriate and Effective Care

To be effective, care coordination needs structure. This includes defining a model that focuses on the entire care team and ensuring standardization of the model throughout the organization. At Cleveland Clinic, our team model includes our associate chief of staff for clinical integration, Dr. Catherine Keating, our associate chief nursing officer for ambulatory services, Janet E. Fuchs, MSN, MBA, RN, NEA-BC, as well as our organization’s care coordination and value-based care teams, in addition to our nursing team. Together, our goal is to develop and refine the process of care – from managing transitions of care to cultivating our EPIC tools to facilitate communication across the care continuum. To aid in our efforts, we’ve created a multi-disciplinary care coordination task force, an educational campaign directed toward identifying care coordination, how it works and the impact it has, and a care coordinator intranet site equipped with community and education resources. Additionally, we’ve established an affinity group that serves as the guiding team in furthering the development of care coordination throughout our organization. One of the most important pillars to our success has been collaboration. Our nurses work with case managers, care coordinators, home care and community agencies to coordinate the treatment of high-risk patients throughout all aspects of their care. This collaboration increases the chances that our patients are making follow up appointments, are involved in transition planning and have self-management and medication update support. Also, very important to the process is the utilization of staff to their highest levels of licensure. While each caregiver’s role is vital, one of the most important is the advanced practice nurse. Cleveland Clinic’s approximately 1,000 advanced practice nurses serve as the patient’s primary liaison. They are a cost-effective provider, aid with physician productivity, help patients access care, enhance the continuity of care, and they focus on prevention, wellness, patient education and promotion of compliance.

Engaging Patients

Care should be planned, delivered and coordinated seven days a week, in all facets of an organization, using evidence-based protocols that focus on long-term outcomes. And, patients and their family members should have an active role. At Cleveland Clinic, care coordination is aligned with our value-based care principles to fully engage patients in their care. These principles, include:

  • Safe: Helps reduce medical or administrative errors.
  • Effective: Based on science.
  • Timely: Care delivered without delay.
  • Patient-centered: Responsive to patient and family needs and preferences.
  • Efficient: Limits unnecessary referrals and avoids duplication of tests.
  • Equitable: Availability and quality of care is accessible to all.

Engaging patients better connects them with their care and gives them a voice in their care path, while also allowing providers to effectively assess a patient’s motivation for improving their health status.

Evaluating Success

Today more than ever, care is viewed from prevention, treatment and management standpoints, including educating on preventive care, which also reduces hospital admissions, to teaching how to self-manage a disease. Success in care coordination is truly a team effort. As we strive to impact a patient’s care, keep them well and reduce total health care costs, success can be measured by evaluating patient satisfaction and engagement, as well as decreased length of stay, emergency department visits and readmission rates. For optimal success, ensure your health system’s care coordination plan encompass strong organizational champions, and is backed by enterprise-wide buy-in and commitment, especially from C-level professionals. Identify and clearly define actionable goals that are aligned with your business objectives, continually invest in care teams, share accountability, and take note of those strategies and tactics that work as well as those that don’t.  

Written By: K. Kelly Hancock, ECNO