We’ve been talking about using health information technology to leverage both algorithmic automation and expert-human execution for your coordinated care and population health management program. Our last post introduced the first step to effective and efficient collaborative care: Population Determination & Outreach. After defining the patient population in need of care coordination and successfully reaching out to this group, it’s time for the second stage: Care Team Assignment & Composition.
Whole-patient care is not only person-centric, but also community-based. So after determining and reaching out to the people who need it most, build the team that makes collaborative care possible. Different programs will go about this in different ways, such as having pre-configured care teams that patients are assigned to, or assembling providers the patients are already seeing into a team. There are a number of viable paths to the same end of care-team assignment.
Here’s one approach to putting together that multidisciplinary, yet cohesive team of healthcare providers.
Whole-patient care takes whole-team collaboration.
Traditionally, primary care (and, to a lesser extent, specialty care) has has operated with relative autonomy, being both the frontline healthcare provider, and often the all-encompassing one as well. Most patients have one general physician and only seek outside assistance when a serious problem arises – typically at the request of the primary physician.
Perhaps gastrointestinal distress crops up, and the family doctor is ill-equipped to accurately diagnose the condition. He’ll send the patient to a gastric specialist, who is able to run the necessary tests and determine what pathophysiology is lurking beneath the physical symptoms. Appropriate treatment follows from there, likely in a silo by one or the other of those healthcare providers.
But the tides are changing. In an attempt to bring down costs of care, more complicated patients with a host of life conditions (not all medical) have become the target of greater efforts to manage their entire care continuum, thereby reducing costs and improving the quality of outcomes. Increasingly, medical professionals and communities alike are recognizing the importance of building a multidisciplinary team, accepting the team-based approach as the only way to truly accomplish whole-patient care coordination. It’s simple logic: Treating a whole person requires a diverse team of specialized professionals working together.
When building this heterogeneous, yet seamlessly collaborative team, the key is making sure that each aspect of the patient’s wellbeing is represented. This includes, but is not limited to, the following fields:
- Behavioral health
- Social stability
- Acute medical care
- Specialty care
- Routine primary & preventive care (i.e., general health)
From individual physicians to institutional providers (e.g., hospitals), social workers to population health managers, and psychologists to specialists, experts in all required disciplines to address the variety of patient issues must come together to create a community that not only offers the appropriate help to patients, but also encourages them to seek it when (and from whom) they need it. Once the teams are built, it’s time to choose the best ones to suit each patient.
Assignment: Matching the patient to the team.
In order to optimize whole-patient care coordination, each individual should be assigned to the team that’s best equipped to diagnose and treat his or her specific set of conditions. Team assignment should not be a complicated or random process: There must be clear, concise criteria for assigning patients, as well as a rationale behind these guidelines that is solid and agreed upon by every member of the multidisciplinary care team.
Typical determinants may include:
- Disease type
- Chronic versus acute
- Prognosis and management goals
- Patient choice
- Patient extended needs (e.g., housing assistance)
- Provider availability
- Treatment protocols
- Collaborative strategy
Once you’ve defined the proper guidelines for assigning patients to teams, the supportive technology can be used to knit together appropriate care coordination teams.
Technology: Making your care teams efficient.
While it’s incredibly important not to lost sight of the humanity that’s integral to a whole-patient care coordination – focus on people, not patients – it’s just as important not to let the efficiency of your program slip.
This is where health information technology and healthcare apps are instrumental. With the right types of integrative software, many of the vital aspects of whole-patient care may be automated. Automation reduces error, streamlines workflow and frees up human brainpower for other important tasks.
- Management of team creation.
With care coordination software, it’s easy to coordinate teams across multiple fields. One example of a technology-supported process might be:
- You enter information about the medical providers in a given network.
- The software uses these contacts to build a database.
- The software then categorizes providers by their role in the care continuum, contribution to workflow, or other such factors that undergird the creation of the most logical and comprehensive teams.
With teams that feature experts spanning multiple disciplines, fewer questions are left unanswered and many more needs are addressed.
- Automate patient assignment.
Using algorithms, care coordination software may be programmed to assess patient diagnoses and other factors in order to assign patients to care teams, or assigning primary custodians of care among the relevant care providers.
- Automate reporting and alerts.
Care coordination technology solutions should enable alerts which are configured to keep the entire care coordination team updated on the status of the patient. These alerts may cover the progression of the patient’s condition, monitoring of significant healthcare encounters (e.g., admission to a hospital) and fulfillment of the prescribed coordinated care plan activities by providers and patients. Alerts may lead to specific actions needed to be taken by the care teams, or contribute to comprehensive reporting on patient care.
Once you’ve built and assigned your care teams, it’s time for the next two steps in strategic collaborative care and population health management: Coordination Of Care and Measurement & Improvement. Stay tuned for tips and best practices to streamline and refine these stages in your program.