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Care Coordination: Closing Gaps Along the Continuum

Primary care practices expected to play pivotal roles

A new report from HealthLeaders Media reveals how providers are discovering and closing gaps in care not just within their own organizations, but across the care continuum.

As the movement toward value-based reimbursement continues to accelerate throughout the health care industry, this transition necessitates the ability to manage costs and improve outcomes simultaneously, the report notes.

Primary care practices are expected to play pivotal roles in coordinating care. Overall, 41% of surveyed health care leaders said their care transitions with primary care were not sufficiently strong. This included 45% of health systems, 40% of hospitals, and 50% of those in long-term care/ancillary services.

Because care coordination in the form of patient transfer within an organization is a well-established activity, attention to outpatient venues may yield more results, the report suggests. Hospitals specialize in providing acute care and interact with a small portion of the overall patient population. Outpatient environments, therefore, will have a broader effect on population health.

A principal benefit of participating in a network is access to information technology (IT) and analytics infrastructure, the report observes, and yet just about the same percentage of those who were in narrow networks (52%) as those who were not (46%) said that analytics needed to be enhanced for clinical outcomes to improve. Indeed, 66% of leaders from health systems — a setting that is more familiar with analytics — included analytics among their top items requiring enhancement to improve clinical outcomes, compared with 46% overall.

Nearly all of the respondents (87%) had incorporated into their care-coordination strategies the concept of the primary care physician as the director of the patient’s overall health. The percentages from medium- and high-revenue organizations were nearly identical (92% and 91%, respectively), with low-revenue organizations slightly lower at 83%.

Leading the list of conditions for which organizations had dedicated or expected to dedicate a full- or part-time staffer were diabetes (68%) and heart failure (65%). For both conditions, care- management staff assignments were cited more often by large organizations than by small ones: 86% of high-revenue organizations had staff assigned to diabetic patients compared with 63% of low-revenue organizations and 70% of those with medium levels of net patient revenue. Three-quarters (75%) of medium-revenue and 79% of high-revenue organizations had assigned care managers to heart failure patients compared with 60% of low-revenue organizations.

It will be interesting to see, the report says, whether already over-extended primary care physicians will be able to add one more major area of responsibility to their busy practices. This also raises the question of whether care coordination needs to be viewed as an independent and new role, with its own business and clinical models.

Several companies are already offering care-continuity solutions, and it is likely that this market will continue to expand, the report notes.

Source: HealthLeaders Media; July 22, 2015.

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