We are finally in a position to improve health care and reduce costs. Rapid advances in evidence-based therapies and practices, the implementation of electronic health records, the emergence of big data as a source of clinical inspiration, and new payment models have improved our ability to achieve coordinated patient care.

Care coordination means organizing patient care between two or more participants, including the patient, to facilitate the delivery of health care services. Essential to this objective is the ability to exchange information about different aspects of care.

For patients, this means being able to cope with transitions — from inpatient to home to multiple places in between so care needs are met — without unreasonable effort.

For health care professionals, coordinated care signifies patient- and family-centered activity to assess and meet patient needs. It requires knowledge of where the patient is and what is happening to him or her. It means directing the patient to the right place to achieve a good health outcome through accurate exchange of information.

Can we achieve this? Yes. But remember that care is delivered according to incentives. There is no future for fee for service in the emerging world of bundled payments, accountable care and patient-centered medical homes. And there is no way to survive these new patient models without effective coordination of patient care outside hospitals and medical centers.

Partnering with Nonhospital Providers

There are no easy fixes. Improving quality of care while controlling costs in multiple venues is the goal, but it is also the problem. We all know how challenging it is to achieve successful patient outcomes within the hospital. What happens when the patient leaves the hospital for an extended stay at a local skilled nursing facility, or receives care from a home health provider? Will these resources reduce the risk of readmission? Can the rehabilitation partner be trusted to operate on behalf of the patient or will it make maximized reimbursement its highest priority?
In the emerging accountable care world, these are key questions. It is becoming increasingly clear that good care coordination must rely on workflow and communication tools that extend the capabilities of any one health care organization or provider network.

We don't have that now. Doctors are caught in the system, feeling overengaged, overarchitected, overcontrolled. The trust that the patient has always felt for caregivers barely exists, the relationship defined increasingly by drop-down menus, tabs and forcing functions.

Another example of the absence of meaningful care coordination is evident in the relationship between the doctors in the hospital and the caregivers who take over for them when patients are discharged. As much as 90 percent of care occurs in acute facilities, but hospital personnel infrequently empower downstream providers, only occasionally share technological resources, and rarely give them the trust and respect their responsibilities should confer upon them.

Instead, physicians in hospitals forget about this component of patient care, simply assuming that the role will be filled. Hospital doctors often don't know where their patients go or whether they are being cared for. With as many as 200 skilled nursing facilities within driving distance of the medical center, the doctor can't tell one from another. Meanwhile, the patient may decide on one closer to home than one near the hospital — but there is no mechanism to track which one the patient chose, or if or what kind of follow-up care may have occurred.

Preventing Hospital Readmissions

How can connections between patients and their doctors be restored? What can be done to forge links among all of the caregivers who treat patients? Can we effectively reduce readmissions?

Readmissions typically occur when patients don't know what they are supposed to do, when they cannot communicate with a provider, or when high-risk patients are not managed in real time. They are “going off the rails,” meaning they are on the road to readmission.

But this can change if we link technology to mobility and social communications, if we design tools that monitor patients in real time, if we employ remote monitoring to keep tabs on patients to ensure that they take care of themselves and to intervene when, for example, they panic. Instead of rushing back to the hospital, the patient can count on a home visit by a nurse.

New Payment/Treatment Models

These goals are within reach if we view pay for performance as a transformative opportunity to develop personalized care plans that forge instant communications between patients and the entire care team. These goals can be obtained if doctors and patients negotiate a wellness agreement, which will bring the two together and permit others to engage in the patient's care. And care coordination can be achieved if there is a treatment plan based on clinical evidence, mutual understanding and trust that the plan will work.

It would allow the patient and the provider to define a path to wellness in a manner that is not buried in a specific EHR or patient portal. It would instead deliver a connected personalized care plan for each patient, enhancing the likelihood of recovery, reducing the occurrence of readmissions, and bringing the costs of health care down.

We are at a critical juncture on the road to better health care. Care coordination is the route to that destination.

Joel Splan is the CEO of PinpointCare in Chicago.