Care coordination deficiencies in the U.S. healthcare system can be so frustrating that they are (almost) comical. That is a message patient activist Jessica Jacobs aired as she advocated for healthcare operational efficiency improvements and care coordination. Until her death last month, Jacobs blogged and used social media to draw attention to America’s problems with disjointed healthcare. She did this by sharing stories of the numerous system failures she experienced firsthand as a patient with complex care needs. While she occasionally made light of the industry’s shortcomings, Jacobs’ struggles and her powerful message about the need for better care coordination have caught the attention of many healthcare leaders.

Although Jacobs weaved witty humor throughout her stories about the healthcare breakdowns she witnessed, most would agree that her experiences were actually much more maddening than funny. One of the things Jacobs found most frustrating (as she cycled through various hospitals and saw handfuls of providers and specialists) was the fact that no one seemed to be “in charge” of helping her manage her two rare—and very serious—health conditions. There was no one leading the fight to coordinate all the different parts of care. That responsibility fell on her as a patient.


Care coordination

Simply put, care coordination is the idea that all specialists treating a patient should be communicating and sharing information to ensure that everyone is acting as a team to meet the patient’s needs. This includes reporting all results back to a primary care physician or to someone coordinating patient care and ensuring that labs, specialists, hospitals, and long-term care facilities are working together to communicate information quickly and appropriately. It’s about primary care physicians, nurses, technicians, specialists, and caregivers collaborating on patient care rather than working as separate entities. Unfortunately, this is far from what Jacobs experienced, and her situation is not uncommon. Care coordination breakdowns are everywhere, and they are not exclusive to patients with complex health needs.

A study conducted for the National Partnership for Women & Families found that 74% of those patients surveyed said that they wished their doctors talked and shared information with each other; 45% said that they have had to act as communicators between doctors who were not talking to each other. So, it isn’t surprising that when The Commonwealth Fund ranked the healthcare systems of 11 industrialized countries, the U.S. was not ranked highly for its ability to provide coordinated care. In fact, in comparison to the other countries studied, the U.S. placed last in efficiency—largely due to lack of communication among healthcare providers.


Patients should not carry the burden

Patients, like Jessica Jacobs, should not carry the burden of relaying information across providers. Not only is it is not their job, but it is not something patients want to do (or are even able to do) when they are sick. Unfortunately, in many cases, it is unclear whose job it really is to coordinate care. This needs to change.

Confusion about who is managing a patient’s care—and lack of coordination among caregivers—is pervasive, contributing to the estimated 250,000 deaths from medical errors each year. Many patients and healthcare professionals assume that primary care is in charge of care coordination. Jacobs shared this view as evidenced by the following excerpt from an email she sent to her primary care physician:

The majority of my friends are allied with the healthcare field—doctors, health lawyers, nurses, health administrators—and all ask “who’s coordinating all of this?,” to which I say I am and then they all stress about who is going to take over when I start puking and can’t get off the floor on my own.

I’m not sure where they got the notion that my primary care physician should coordinate my care, maybe they were looking at NCQA’s patient-centered medical homes model, or found a copy of the Accountable Care Organization regulations from CMS, or listened to people discuss Obamacare on Late Night with Jimmy Fallon. All I know is that they all say that a PCP is the person to coordinate care.

So, does primary care need to be more active in coordinating healthcare? Yes. But in reality, every area of healthcare needs to be more willing to accept a share of the responsibility for care coordination. This includes primary care, but it is not limited to that segment of healthcare. Once that happens, care can be delivered more efficiently, particularly for those with chronic illnesses and complex needs.


Care coordination agreements

One of the best things healthcare providers can do to improve care coordination is assign accountability. Primary care physicians, specialists, area hospitals, and long-term care providers should come together and establish formal agreements on the roles they will each play in providing care. There are very real benefits to doing this. Care coordination agreements have been associated with decreased costs and increased quality of care. They reduce unnecessary referrals, prevent duplicate assessments, and optimize care.

When developing care coordination agreements, providers should work to set expectations and guidelines surrounding information sharing, establish standard communication protocols, put agreements into writing, and use agreed upon processes to keep all parties informed of clinical developments.

Besides assigning accountability for care coordination, providers should also review clinician workflows. From admissions to diagnostics to patient care to discharge planning to readmissions, healthcare providers need to analyze their workflows and identify process, patient flow, and clinical workflow issues. Then, they need to redesign workflows with care coordination and improved health outcomes in mind.

Additionally, healthcare providers can work to utilize technology to bridge communication gaps. Electronic health records systems are becoming more customizable and interoperable; many have capabilities that allow providers to share information and access accurate, updated patient data. EHRs, which have become widely adopted, can be used to get real-time updates on things like medication changes and test results. EHRs can also be leveraged to send out alerts when patients are admitted or discharged from the hospital. When used to their full potential, EHRs can be useful tools for coordinating care.

Finally, providers across the entire care continuum need to understand that well-managed care coordination includes:

  • Recognizing individual and family goals and needs and putting them at the center of care planning
  • Maintaining strong clinical and organizational support for effectively coordinating care
  • Ensuring care continuity across medical and nonmedical services and from acute to long-term settings


The bottom line

The payoff for investing in care coordination improvements is more than worthwhile. When everyone is working together as a team to make sure they are all collaborating on patients’ needs, quality of care goes up while costs go down, patient outcomes improve, and satisfaction levels are higher.

Richard Royer, MBA
Richard A. Royer has served as the CEO of Primaris since 2001. He has extensive administrative healthcare experience and is actively involved in several statewide healthcare initiatives. In 2006, he was appointed by the Missouri governor to the Missouri Healthcare Information Technology Task Force and chaired the resources workgroup. He also serves on the Board of Directors as Treasurer for the Excellence in Missouri Foundation. In his over 35 years of medical business experience, he has held positions as CEO at Cuyahoga Falls, Ohio, General Hospital; Executive Director of Columbia Regional Hospital in Missouri; and Founder and President of Avalon Enterprises, a medical financial consulting firm.


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