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The Challenges of Coordinating Care for Complex Patients

The core aim of care coordination is to identify patients in need of more intensive collaboration and synchronize care delivery. To achieve this, critical patient information must be known and communicated at the right time to the right care team member.

How Care Coordination in the US Stacks Up

A 2019 Commonwealth Fund study found that fewer primary care physicians in the US receive information about their patients as they navigate the care continuum when compared to 11 countries: Canada, Australia, New Zealand, France, Germany, the Netherlands, Norway, Sweden, Switzerland, and the United Kingdom.

Fewer than half of US primary care physicians receive information from specialists on changes to a patient’s medication or care plan. Only 48 percent and 53 percent of physicians reported being notified when one of their patients visited an emergency department (ED) or was admitted to a hospital, respectively.

Without critical information like ED visits or care plan changes, physicians are operating in the dark when it comes to caring for patients. Coordinating care for at-risk patients becomes possible with technology-fueled insights delivered in real-time.

Rising to the Challenge

A lack of interoperability and visibility into patient movement can make coordinating care for patients challenging. In a recent Healthcare Innovation article, Matt Weltner, Director of IT at Navos Mental Health Solutions in King County, Washington shared, “One of the big challenges we have without interoperability in healthcare is that you just don’t know when your client goes into the hospital, yet you still have a responsibility to see him or her.”

Next, we’ll look at how care coordination, when done right, can improve both financial and clinical outcomes. Read parts two and three to learn the following:

  • How care coordination has been demonstrated to decrease both emergency department and inpatient utilization, particularly for high-need, high-cost patients
  • How real-time collaboration and complex care management can cut down on the costs associated with caring for at-risk and high-risk patients

Brittany Eastman
Content Marketing Specialist