The rise of care coordination – led by both regulatory changes and industry shifts – is prompting healthcare systems to think about new care coordination strategies between hospitals and downstream post-acute care providers. Many of the organizations that we work with are looking for better ways to coordinate post-discharge care. Because there’s such an interest in how to not only establish care coordination teams, but how to make them successful, we invited Julie Mirkin to join our recent post-acute thought leadership webinar series. Julie is the Vice President of Care Coordination at NewYork-Presbyterian Health System and is responsible for the coordination of care for every patient in the organization’s 2500 beds. Julie shared her strategies on how to build care coordination teams, and how to make those teams effective.
Working in Teams
Care coordination is the process of managing a patient’s healthcare for their lifetime. It includes managing patients through the system, serving as a resource and an advocate, helping patients get access to care, and monitoring compliance with plans of care, and is critical to any healthcare organization.
This level of coordination takes teamwork (as noted in several recent studies). At NewYork-Presbyterian, care coordination teams are set up in triads with physicians, nurses and care coordinators working together. Care coordinators in this case consist of RN care managers and social workers – a dyad. The care coordinators manage patient care from admission through post-discharge to make sure patient needs are being met.
With this structure, a question that Julie often hears is: How do you get the social workers and RN care managers to work together and to work in tandem with the RNs on the unit and the physicians? She cites “Why Teams Fail” from The Five Dysfunctions of a Team as a framework for successful team building. Functional, productive teams, must address the following:
- Lack of trust: Everyone on the team must trust each other, know each other on a personal level, understand roles and complement each other.
- Fear of conflict: Address conflict – this is particularly important in care coordination – recognizing that conflict exists – whether it’s interdisciplinary with a physician and a social worker, or with a payer or post-acute partner. Conflict must be addressed so that it can be managed effectively.
- Lack of commitment: Everyone must be committed to the work and the vision before they can join the team.
- Avoidance of Accountability: Everyone is accountable – both inside and outside the hospital. If the social work team is supposed to start discharge planning on day two of a patient stay, it must start on day two. Similarly, post-acute partners need to be held accountable. If a skilled nursing facility says that they will accept a patient and provide certain services, they are accountable for that patient and those services.
- Lack of Attention to Results: Without good results, the structure and process don’t mean anything. A lot of attention paid to outcomes helps teams operate at a higher level.
Three Dimensions of Care Coordination
In addition to the framework for establishing teams, Julie also discussed three dimensions of care coordination performance:
Clinical effectiveness: One of the biggest components of clinical effectiveness is the entire care transition management process: what happens to the patient post-discharge is equally as important as what happens to them during their hospital admission. So, it’s critical to make sure there is a plan of care in motion that meets the patient’s needs, and that the plan is monitored through the acute, post-acute stays and beyond.
Patient outcomes: Patient satisfaction with care is both an internal and external measure. Not only is providing positive patient outcomes the right thing to do, there is a transparency around those outcomes – through HCAHPS and other surveys – and patients use this information to choose providers.
Finance: This is where the rubber hits the road; the care coordination team has significant obligation to ensure the financial stability of the organization. The team is instrumental in managing LOS, medical necessity, working with payers, looking at avoidable days, managing readmissions through effective discharge planning, and working with managed care team. The responsibility that falls on the team for the financial outcomes of the entire organization is a big reason why addressing the five dysfunctions is essential.
The bottom line: care coordination used to be a nice-to-have. Now care coordination as a system, process and a department is a significant value-add, and is critical to the success and longevity of the organization.