Health care providers know first-hand how difficult it is to navigate today’s health care system, especially for patients suffering from multiple chronic conditions. That challenge is even greater for Medicare beneficiaries having a handful of doctors or specialists monitoring their health and prescribing medications. On top of this, some patients may have extenuating circumstances, like not being able to drive or speaking a language other than English, that makes seeing providers or filling prescriptions more challenging.
Now imagine if those beneficiaries had someone to help them manage appointments, track and properly take their prescription drugs, and connect them with community resources for transportation or translation assistance. This is exactly what happens with coordinated care.
Seniors are especially in need of coordinated care as more than two-thirds of Medicare beneficiaries have two or more chronic conditions, such as diabetes, heart disease, kidney disease or asthma and allergic diseases, and the typical beneficiary is being served by two primary care physicians and five specialists across four different practices.[i] These situations create much opportunity for medical errors, reduced quality of life, and higher costs if there is no one coordinating care.
The goal of coordinated care is to make sure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. Often times, a patient’s primary care physician will serve as the “care coordinator,” but others – such as nurses, social workers, or other providers – can also serve in this role. The key is that the coordination is deliberate and that all people involved in the care of the patient – the primary care physician, specialists, social worker, of course patient and family care giver, and others – be part an active part of the team.
Health care professionals have varied care coordination responsibilities, however, the following tasks are good suggestions for helping beneficiaries navigate the health care system[ii]:
- Engaging the patient and his or her caregivers in the development of an individualized care plan.
- Ensuring that the patient and his or her caregiver understand their role outlined in the care plan and feel equipped to fulfill their responsibilities.
- Identifying all of the barriers—psychological, social, financial, and environmental—that affect the patient’s ability to adhere to treatments or maintain their health and linking patients with community resources to facilitate referrals and respond to social service needs.
- Assembling the appropriate team of health care professionals to address the patient’s needs.
- Assisting the patient in navigating the circuitous network of providers.
- Ensuring the patient’s electronic health record appropriately reflects the most up-to-date information and is easily accessible to all care team members, including the patient.
- Facilitating appropriate and timely communication between care team members.
- Following up with the patient periodically to ensure their needs are being met and that their circumstances and priorities have not changed.
Cultural competency is another cornerstone of care coordination. Given the diversification of the population of the United States, it is imperative that health care systems are able to deliver services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients. It is important to have all kinds of providers – physicians, specialists, nurses, home health providers – who speak Spanish, as many members of the Latino community, especially the elderly, still speak Spanish as a primary language, or as their only language.
The good news is that health plans such as those offered through the Medicare Advantage program are making a difference. A recent study found that health plans are working hand-in-hand with hospitals, physicians, and clinicians to keep improving the way care is managed and delivered. For example, health plans regularly notify providers when there is a gap in a patient’s care, such as failure to refill prescriptions or missed appointments.[iii] The innovative services offered by Medicare Advantage plans are great examples of supporting providers to ensure chronically ill patients getting the right care, at the right time, in the right setting.
Health plans and providers are and will continue to be critical to the success of coordinated care. Working together and accessing the training and tools necessary to take care of patients with complex health care needs is imperative to helping Medicare beneficiaries be as healthy as possible.
As the Care for Us Project continues over the coming weeks and months with focuses on specific chronic diseases, we urge you to visit our blog for updates and follow the Coalition on Twitter.
[i] Thorpe KE, Ogden L, Galactionova K. Chronic conditions account for rise in Medicare spending from 1987 to 2006. Health Affairs. 2010 Apr; 29(4):718-724.
[ii] http://familiesusa.org/sites/default/files/product_documents/Care-Coordination.pdf
[iii] http://www.ajmc.com/journals/issue/2015/2015-vol21-n5/Results-From-a-National-Survey-on-Chronic-Care-Management-by-Health-Plans