Ten Tips for Implementing and Improving Care Coordination

Care coordination is like the air traffic control of health care, says Yul Ejnes, MD, an internist based in Rhode Island who helped develop the High Value Care Coordination Toolkit for the American College of Physicians. Medical practices have done this for years but may not have had the time or resources to focus on it. Now payers are offering incentives for practices to add care coordination. Here are some tips to make the transition.

1 Embrace it. Overloaded physicians may feel that participating in care coordination is more trouble than it’s worth. But evidence suggests that it can improve care, increase patient satisfaction, and reduce costs, which is something that Ejnes has seen in his own practice. “You have to believe it’s important, or it won’t happen,” he says.

2 Start out slowly. Tracy Watrous, vice president of organizational content management for the Medical Group Management Association, says it’s often not necessary to hire a dedicated care coordinator. Practices can start by shifting job responsibilities so that staff can devote time to care-coordination activities.

3 Involve staff members at all levels. Staff can share ideas about how to efficiently integrate care-coordination tasks into their workdays.

4 Explore what other practices are doing. Physicians can learn a lot by talking to colleagues at local medical societies or visiting other practices.

5 Focus on areas of biggest impact. Chronic care management, transitions between care settings, and referrals offer the biggest opportunities for quality improvement and cost reduction.

6 Open lines of communication. Make sure referring physicians and local hospitals know how to relay when one of your patients is admitted, treated, or discharged.

7 Recognize the patient’s role. Patient engagement plays a big role in care coordination, says Watrous. Find ways to involve patients in treatment planning and ensure that they have the information and support they need to carry out the plan between visits.

8 Make small changes. Watrous says 1 internal medicine practice improved diabetic foot care by asking patients with diabetes to take off their shoes and socks at office visits. This way, physicians could quickly check their feet.

9 Use technology. Most electronic health records can generate lists of patients who are due for preventive care. Reduce duplicate testing by using your state health information exchange to check for laboratory results and studies ordered for your patients by other physicians.

10 Take advantage of available tools. The American College of Physicians, the Medical Group Management Association, and other state and national physician groups and payers offer free and low-cost resources for training staff and implementing care coordination.