Skip to main content
Rural Health Information Hub

Feb 21, 2013

Care Coordination Keeps Patients, Providers in the Loop

by Candi Helseth

Definitive data is demonstrating that team-based coordination of care improves overall patient health and reduces costs. That's good news for the United States, which ranks only 37th in the world for health care outcomes while spending more than $2.6 trillion dollars every year on health care, according to Dr. Ted Epperly, author of the book, Fractured: America's Broken Health Care System. Coordinated care pilot projects and models have been implemented in every state, Epperly said, and their integrated, patient-centered focus is proving that managing patient care continuums and transitions results in better care and less cost.

In past issues, the Rural Monitor has featured coordination of care in various medical disciplines. Here's a look at three providers' coordinated care services and the progress they've made since their stories were first published here.

MEDICAL HOMES: Keeping patients in a coordinated loop

A Community Care of NC care manager meets with patients to go over their needs as part of its medical home program.

In North Carolina and Idaho, providers with long-term commitments to care coordination have adopted the National Committee for Quality Assurance (NCQA) patient-centered medical home (PCMH) model (see sidebar). Begun in 1991 to coordinate care for Medicaid patients throughout the state, Community Care of North Carolina (CCNC) began its own PCMH model in 1998 and is now working toward NCQA PCMH levels. In Idaho, the Family Medicine Residency of Idaho (FMRI), where Epperly is CEO and program director, achieved the NCQA's highest ranking for medical clinics last fall. Also, the Health Resources and Services Administration (HRSA) named FMRI a Teaching Health Center. FMRI encompasses four community clinics in rural Idaho's Treasure Valley. (Previous stories on FMRI and CCNC appeared in the Rural Monitor, Spring 2009, no longer available online).

Since 2009, when CCNC was first featured, this community-based regional network system has grown from 891,000 to 1.26 million enrollees. More than 90,000 CCNC enrollees are Medicaid recipients; 981,000 are children and 269,000 are termed ABD (Aged, Blind, and Disabled). Communications Director Paul Mahoney said ABD patients typically are acutely physically ill, have multiple chronic disease diagnoses, are on numerous prescription medications and are economically disadvantaged. Nearly one-half have some element of mental health comorbidity. To strengthen the local resources, CCNC has increased the number of caseworkers from 600 to 800 and added a pharmacist and behavioral health coordinator to each of its 14 networks covering all 100 N.C. counties.

According to Mahoney, the addition of a behavioral health coordinator breaks down the silos between medical and behavioral health practices. CCNC's experience has demonstrated that treatment of underlying mental health issues also improves the patient's physical condition. The use of a network pharmacist ensures better identification of patients on multiple prescriptions and results in improved monitoring of correct medication usage.

“Our model has proven itself,” Mahoney said. ” Our care managers live locally and know the local resources. We also have a telephonic call center that checks on patients. All these touch points across the state and the home support we provide to patients produces better outcomes.”

In Idaho, the NCQA model also works well at the clinic level, according to Epperly. FMRI demonstrated adherence in six categories to achieve PCMH recognition. These included areas such as enhancing patient access and continuity, planning, tracking and coordinating care, and measuring improved performances. Epperly said combining resources as a teaching center with Rural Training Tracks (Rural Monitor, Spring 2011, no longer available online) and as a patient provider has multiple benefits. Underserved people receive coordinated care. Medical residents in training supplement rural workforce demands.

“We're marrying up need and demand,” Epperly asserted. “These rural experiences influence medical residents to locate in rural areas when they graduate. It's a win-win situation.”

The PCMH model promotes partnerships between patients and team members. FMRI team members involved in a patient's medical home include a primary care physician who coordinates team efforts working with family medicine residents, nurses, receptionists, schedulers, medical assistants and other professionals. FMRI's model also coordinates the patient's care when other medical interventions, such as hospitalization, are required.

“So much of health care becomes a black box for patients, who often don't understand what is happening or have to decode what is going on with their care,” Epperly commented. “Our patients become part of the team. They own their own information.”

HOSPITALS: Implementing coordination solutions

For patients who are hospitalized, coordinated care systems reduce errors and improve patient satisfaction. Team STEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) was developed by the Department of Defense's Patient Safety Program and the Agency for Healthcare Research and Quality (AHRQ) to encourage hospitals to implement evidence-based teamwork systems to address manageable projects, one issue or department at a time.

McCune-Brooks Regional Hospital (MBRH), a critical access hospital (CAH) in Carthage, Mo., implemented TeamSTEPPS to improve hand offs, the point of care where patients are transitioned during shift changes, between departments, etc. (Rural Monitor, Fall 2011, no longer available online). With TeamSTEPPS barely underway, MBRH was catapulted into being the region's primary health care facility after a tornado struck nearby Joplin and its hospital. MBRH patient census and the number of surgeries tripled. Then in January 2012, MBRH affiliated with Mercy, a health care system with 400 clinic and hospital locations in the Midwest.

“The last year has been a blur of increased demands and constant change,” Chief Operating and Nursing Officer Sherry Lopez said. “We still use TeamSTEPPS and it complements the new programs we've adopted as part of the Mercy system. But some steps we've been using with TeamSTEPPS are changing because of the processes built into the new electronic medical records (EMR) system we're implementing that meets meaningful use standards.”

Integrating with Mercy has enhanced their ability to better coordinate care across systems, Lopez said. She said Mercy did research to determine the primary diagnoses contributing to patient readmissions. Based on that knowledge, care paths are developed for each diagnosis—such as congestive heart failure—that essentially outline the most effective steps hospital staff must take to positively impact that patient's outcome. Additionally, patients entering any system under the Mercy umbrella area are assured of getting the same continuity of care because these patient care paths are being used throughout the system and all 31 Mercy facilities are integrated electronically.

“Mercy develops the care paths within our EMR system so everyone working with the patient has that knowledge,” Lopez said. “It's spelled out for us what needs to happen day by day to get this patient with this particular diagnosis better and ready for discharge. The care plan also has steps for us to be a liaison to get the patient back to their primary care and in the ambulatory setting to prevent them from being readmitted again. Mercy has gotten our system set up and they bring in an implementation team that has a detailed plan and knows how to get everything running. It's pretty amazing stuff.”

Lopez said McCune-Brooks couldn't have implemented such technology without affiliating with a larger system. “We could never have accomplished this alone. Overall, coordinated care continues to improve, she said. “We believe that these practices will provide our patients with the highest quality of care in the most efficient manner. We currently have seven paths developed and will have more than 20 in place by July 2013.”

CHALLENGES: Meeting care coordination criteria, garnering reimbursement

Dr. Ted Epperly visits with a patient at Family Medicine Residency of Idaho where, as its CEO and program director, he promotes the concept and practice of coordinated care.

While rural providers don't seem to dispute the value of health information technology (HIT) in improving care coordination, associated costs and workforce demands can be overwhelming. Meeting NCQA medical home model standards, which also are best achieved using EHR systems, has been “a rigorous process,” Mahoney said. From Oct. 2010 to September 2012, CCNC has increased its NCQA compliance from 38 to 431 levels.

“With the Affordable Care Act requirements requiring more from us plus cuts in reimbursements for small hospitals, there is no way we could have made these changes and implemented this quality of EMR alone,” Lopez said. “I think there will be a lot more integration of small hospitals with larger systems in the future.”

Lack of reimbursement also makes it difficult for already financially pressed rural facilities to implement care coordination models. Providers are reimbursed for diagnosing and treating patients, but not for time-consuming practices involved in care coordination such as wellness consults and referrals. According to AHRQ's PCMH Resource Center (no longer available online), current fee-for-service arrangements also do not provide adequate support for the many care coordination activities and resources needed to serve patients with complex needs, such as the elderly or the disabled.

“If it's important, there needs to be reimbursement for it,” Epperly stressed. “Coordinated care has to be valued. When we ensure that a person's health is well managed, that person's overall health improves.”

OUTCOMES: Improving health and saving money

CCNC is proving that coordinated care improves health and also saves money. With quality and efficiency improvements, inpatient and emergency hospital utilization decreases, Mahoney said. A December 2011 study confirmed that the state of North Carolina saved nearly $1 billion in Medicaid acute care expenses from 2007 to 2010.

Now CCNC is partnering with other providers to improve coordination of care. In addition, its cooperative effort with GlaxoSmithKline (GSK) is targeted toward North Carolina GSK employees. CCNC is also working with the Centers for Medicare and Medicaid Services (CMS) on a multi-payer program that covers seven rural North Carolina counties.

“We can't afford not to do this as a nation,” Epperly asserted.

Sidebar: What is a Patient-Centered Medical Home?

Back to: Winter 2013 Issue