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I Know It When I See It: Coordinated Care

illustration of hands using a table to look at medical information and coordinate care

I’ve spent many years working with healthcare providers to implement and optimize care under bundled payment programs, beginning with diagnosis-related groups (DRGs) that bundled acute care service payments. I’ve managed care for three generations of family members, in two countries and five states. I’ve been through numerous elective and emergency procedures.

Yet I’ve never experienced truly coordinated care until just last week, when my husband had his hip replaced.

We did our part. We got recommendations from friends and caregivers. We checked credentials and the number of procedures done per year. We got a second opinion from another highly rated provider. And we made sure we had the proper referral from the primary care provider.

After that, the clinic and hospital took over, and the experience was superb.

We left the initial consult with a surgery date, and within 24 hours we were online with the smartphone-based patient app, scheduled the phone screening, and lined up for the four-hour-long, team-based, coordinated pre-op visit. The hospital, in Virginia, handled our co-pay before we arrived, met us at the door, and kept me, as the family care provider, completely informed throughout the entire process.

My husband started physical therapy within an hour of reaching his hospital room. Before we left the next day, the home-care providers, back in Maryland, had already scheduled their initial visits, and the patient engagement app was prompting Gary to begin his rehab exercises.

Best of all, we haven’t had to coordinate anything with the insurance company!

I have no idea whether the hospital, home-care service, and orthopedic practice are being paid under a bundled payment arrangement or not, and frankly, it doesn’t matter to me. My husband is already more mobile than he’s been in months, and the process has been nearly seamless.

So, what could be better? The information technology.

Every healthcare encounter represents an opportunity for field research. In this case, my primary observation is that human components of the care process were highly collaborative and coordinated, the IT connecting our providers and payers was only somewhat so.

  • There are silos within the integrated hospital information system. The same questions were asked over and over, even in the team-based pre-op visit, all of which occurred in a small office suite. (And no, I don’t mean the patient safety questions verifying identity, etc.)
  • There was clearly no automated information handoff from the hospital system to the home-care system. We weren’t confirming information they already had, but rather assisting in primary data capture.
  • Our payer’s care management process was triggered by any referral to a surgeon, but the care manager had absolutely no visibility into any of my husband’s two years of conservative care, and each conversation required him to manually recite his entire care history.

The good news is that the providers I asked spoke positively about the EHRs they were using – both of which are products of InterSystems software partners. And the other good news is that with the right human handoffs, we can provide a coordinated care experience for patients.

Now we just need to get the computers on board with the whole thing. My colleague, Lynda Rowe, recently pointed out that bundled payment depends on bundled data, so we’ll keep working on that part, while Gary keeps practicing stairs with his well-coordinated new hip!

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