Healthcare News & Insights

3 keys for hospital care coordination programs

Hospitals are being asked to take more responsibility for care coordination, and healthcare executives need to take the lead in preparing their hospitals to do so effectively. While it may be difficult to put a system in place to coordinate patient care, the benefits — both for patient care and reimbursement — can’t be denied.  

ThinkstockPhotos-509828885According to an article from the American Hospital Association’s Hospitals & Health Networks publication, executives can start bolstering their care coordination program by creating a checklist to ensure it has all the required elements.

The checklist should lay out the most important steps required for a care coordination program, along with who’s responsible for putting them into place.

Make sure your hospital’s care coordination program contains the following three elements:

1. Accountability

Hospital staff members need to be held accountable for their roles in maintaining the continuum of care. A communication breakdown in one area could lead to a patient missing a crucial follow-up appointment post discharge, which puts recovery in jeopardy.

To that end, it’s important roles are defined and clearly assigned. So it’s a good idea to create a dedicated team that solely focuses on managing patient care. Each member of the team should have a specific job when it comes to coordinating patient care (e.g., communicating with outside specialists, following up on patients’ test results).

And all members should check in with each other on a regular basis to make sure patients don’t fall through the cracks.

2. Referral tracking

Referrals to other providers are an important part of care coordination for hospitals. Patients who receive the appropriate follow-up care after discharge have better outcomes, including fewer readmissions.

But after referrals are made, it’s rare that hospitals actually check up on patients to make sure they attend their appointments and receive the appropriate treatment. To avoid these issues, hospitals need to have a referral tracking system in place to manage post-discharge referrals.

The system should establish a clear protocol that hospital staff can follow to check patients actually complete all required follow-up care.  Staffers should be sure to make direct contact with the patient’s listed primary care physician to keep them in the loop about any upcoming appointments – and to avoid any duplicate referrals.

Information contained in patients’ electronic health records (EHR) systems can help staff better track referrals. It may be wise to ask your EHR vendor if your system can “flag” any records where patients were referred to providers after discharge so staff can easily check in with those patients later on.

3. Patient support

When it comes to care coordination, hospitals can only do so much on their own. Patients need to show up to their follow-up appointments and follow their discharge plans.

Although hospital staff can’t force patients to be compliant with their post-discharge treatment, they can put a support system in place to make it easier for patients to manage their own care.

The foundation for this system can be put in place when the patient is first admitted. Clinical staffers need to give patients the information they need to start taking charge of their own care from the very beginning of their hospital stay, answering their questions in clear layman’s terms.

To provide patients with further support post-discharge, several members of the care coordination team can be assigned to directly support patients and their families.

Team members should make sure patients understand which medical professionals they need to make contact with once they leave the hospital – and why the appointments are necessary. They should also make patients aware of what resources are available to them, including those that aren’t medical in nature (such as community support services).

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