The goal of value based care is coordinated care. According to the American Medical Association, the coordinated care model is “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.”

Coordinated care and the coordinated care approach is the single most challenging aspect of the population health approach and of value based care.

The basic goals of coordinated care are:

-To lower the fragmentation and provide consistent delivery of care by the organization of health care methods across multiple healthcare providers and multiple healthcare venues.

-To more capably manage the transition of care as the patients move across the network.

-To lower the number of hospital admissions by noting and identifying the issues taking place well prior to the need for inpatient hospital care.

-To close the gaps in care so that every patient achieves the best care possible.

-To manage the referrals needed to help maintain patient health while keeping the client within the network.

-To prevent the need for emergency room care of patients with both short term and long term conditions.

The Coordinated Care Methods

There are 5 basic steps in coordinated care that must be taken.

These include:

Connection: Creating a good foundation of clinical and financial systems in healthcare.

Identification: By using great tools, work to get patients placed in specific populations and identify their need for care.

Engagement—Engaging the patient is the best way to ensure coordinated care. Patients must understand their condition and know how best to treat it so that they are more willing to comply with the required treatments and medications necessary to remain as healthy as possible.

Enrollment- Secondary to identification, if necessary or desirable, enrolling a patient into a coordinated care program is vital. Depending on the content of the care plan, and the level of treatment the patient needs, keeping them enrolled may be virtual or face to face.

Monitoring & Revision—Continuity of care is imperative and if a patient should require additional care or develop additional symptoms, the treatment must be available. Continuous monitoring allows the health care team to flag those who have additional problems and treat them appropriately in order to prevent exacerbation or hospitalization.

What makes coordinated care such a success and a necessity is the way in which it can help to prevent needless hospitalization and patient suffering. The number one issue with coordinated care today seems to be engaging the patient. Exploring the best way to engage your patient is going to be difficult, at best.  We address this idea of patient engagement in part 6 of this 7 part series.

Mitch Robbins is an expert as it relates to Interim and Direct Hire Nursing Leadership Recruitment for hospitals and clinics, helping organizations build best in class clinical leadership teams in the USA.

Learn to how to STOP losing your best nurses, IMPROVE your patient outcomes and DECREASE your staffing costs with special guest LeAnn Thieman. Download the free webinar transcript with LeAnn, Hall of Fame Speaker, Nurse, and Co-Author of the book Chicken Soup for the Nurse’s Soul. Download your free copy here.

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