The ABCs of Care Coordination

With so many technical terms floating around in care coordination, it can be difficult to keep everything straight, especially when terms (all too frequently) sound similar. To help, we’ve done a roundup of common terms and definitions. Community care coordination seeks to improve patient health by addressing the social determinants of health directly. This involves partnerships and even integrated delivery models involving primary care, behavioral health, and community-based providers to jointly address all aspects of a patient’s condition.

Which is Which? Clarifying Terms 

Because of the high degree of coordination required, numerous titles have been used to describe the coordination manager: Case Manager, Care Manager, and Care Coordinator. Let’s tease these terms apart!

1. Case Manager

A case manager assesses eligibility for specific programs (i.e. food stamps), enrolls clients in programs, and monitors client progress. The goal is to enroll clients in applicable programs as a means to achieving desired outcomes. In general, case managers work with human service programs such as housing, workforce services, child and family services, food assistance, etc.

2. Care Manager

A care manager works more directly with patients to manage their health conditions and reduce the need for additional medical services. Care managers are traditionally found in hospitals and other clinical settings and often work with patients who have chronic illnesses.

3. Care Coordinator

Care coordination is where case management and care management come together. A care coordinator (or patient navigator) focuses on treating both the medical needs and the social factors (the social determinants of health) that affect the health of an individual. A care coordinator has visibility into all aspects of an individual’s care and serves as the point of contact for patients as they work with providers across the spectrum of care.

Care Models and What Distinguishes Them

In addition to similar sounding job titles, there are also myriad of care models, each with its own unique characteristics (and, again, sometimes similar-sounding names). Some of the more common ones are:

Medicaid Waivers

States can apply for Medicaid waivers to fund programs that target a specific population for health care services. For example, 1915 waivers fund home and community-based care services for targeted populations, to avoid care delivered in higher-cost settings. A state may run multiple waiver programs simultaneously.

Accountable Care Organization (ACO)

ACOs are groups of doctors, hospitals, other providers and medical facilities who voluntarily unite together to deliver coordinated care to Medicare patients with the goal of lowering overall cost while improving patient outcomes. Providers are financially rewarded with a portion of the program savings.

Next Generation ACO

The Next Gen ACO is an opportunity for an ACO with a proven track record to take on additional risk in patient care for potential additional reward. The NextGen ACO model seeks to deliver better patient outcomes at even greater cost savings than under the traditional ACO model.

Managed Care Organization (MCO)

An MCO is similar to an ACO in purpose (lowering cost of care) but differs in the population served. MCOs typically serve patients covered by commercial payers or self-pay patients.

Integrated Care

An integrated care model combines medical health and behavioral health care. Patients may receive services typical of medical care in a behavioral health setting and vice versa. The goal is to increase screening and delivery of mental health services by integrating these services into the care patients already receive.

Each model of care shares common goals, such as delivering better care at a lower cost, but each model uses slightly different methods to achieve the goals. There is great flexibility even within categories: Medicaid waiver programs, for example, can take a variety of different formats as long as they meet the established program criteria.

 

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Demystifying Care Coordination Terminology

As we examine potentially confusing terms in care coordination, let’s review some software terms as well. As even casual computer users know, software has its own specialized vocabulary. Add in the specialized vocabulary used in medical health, behavioral health, and community-based care, and you can see how it can quickly become confusing.

Below are some of the common terms and buzzwords used in describing different aspects of the technology and the industry it serves:

Care Coordination Platform

The care coordination platform is the foundation on which care coordination relies. Using a care coordination platform, with software applications purpose-built for different needs and use cases and a single database accessible across the entire platform (according to the application and role-based access to preserve privacy, security, and HIPAA compliance), providers across the spectrum of care delivery can collaborate on patient needs, communicate with other providers, view results, and monitor outcomes. This platform is the core that unites providers across different disciplines and medical specialties, such as primary care, chronic care, behavioral health, and community care.

Upstream Drivers of Health

The upstream drivers of health are the complex factors outside the scope of traditional medical care that have a direct impact on patient health. This data includes factors such as employment, education, economic stability, food security, home environment, and access to healthcare. The care coordination platform assesses patient conditions related to the upstream drivers of health, records care given to address needs and monitors patient progress against desired outcomes.

Interoperability

Interoperability is the process by which one computer system exchanges data with another system. Data exchange is a necessity throughout the healthcare industry as different providers, care systems, and even individual departments within the same facility may use different software as their primary system of record. A care management platform, such as CaseWorthy, must support common interoperability standards, such as FHIR and HL7.

Comprehensive Care Plan

A comprehensive care plan is a living document that exists within the care coordination platform. This document is created from configured social and physical health assessments and is accessible to all members of the multi-disciplinary care team. Shared assessments, intake and enrollment, care plans, and progress notes are accessible at the point of care so providers are fully informed of all aspects of the patient’s condition. A comprehensive care plan builds on the idea of bringing all patient data together, then adds real-time care-planning and communication, providing true whole person care.

Comprehensive Health Record

The Comprehensive Health Record (CHR) is the term proposed to describe the “next generation” health record that will replace the Electronic Health Record (EHR). The CHR includes all the medical information currently contained in the EHR but adds additional information about the social determinants of health. The shift to the CHR is an acknowledgment by the Health IT industry that medical data alone is insufficient for patient care and that additional information is essential for high-quality care delivery.

Patient Stratification

Patient Stratification is the use of cost trends, chronic conditions, and upstream drivers of health data to identify the individuals most likely to benefit from care coordination. Patient stratification is widely used in population health to target high-risk patients for more intensive treatment.

Patient Engagement

Patient engagement refers to the knowledge, skills, ability, and willingness of patients to manage aspects of their own health care. Patient engagement can range from a patient regularly showing up for (or missing) provider appointments, to participating in health care discussions with a provider through a patient portal, to intensive collaboration with a team of care experts across multiple care disciplines.

The CaseWorthy platform assists providers across multiple care disciplines — such as primary medical care, chronic care, behavioral health, institutional care, home care, and community-support providers — to share data, communicate, and collaborate together to deliver higher quality care. With powerful and flexible interoperability, the comprehensive care plan, applications and components purpose-built to addressing the upstream drivers of health, and increased patient engagement, CaseWorthy gives providers everything they need to deliver the next generation of healthcare.