Visit this page often for weekly blog posts that we think you’ll find interesting and helpful.

Topics may range from “Connecting a care team to effectively implement an individualized education plan” to “Elder-specific issues in care coordination.” We think unlocking potential and enhancing care outcomes includes keeping everyone informed of new and better ways to organize and coordinate care in patient-centric ways…

What Care Coordination Really Looks Like For Most Seniors

Care coordination is a solemn topic in healthcare right now. There is plenty of reason to pay attention to it; Medicare reimbursements will rely heavily on how well it is carried out. Hospital readmissions are a big “No-No” now. Everything should be done by care providers to ensure adequate care, patient safety, and patient follow through with care plans.

Anyone in the healthcare industry knows what a tall order this is. Nevertheless, Medicare requires it through its Medicare Advantage program, and care service providers need to beware of drastically reduced reimbursements for failure to comply.

When many different types of services are working together toward a common goal, how can everyone involved be assured that everyone is doing the right thing by the patient? If one cog in the wheel of care coordination breaks, who is at fault when the whole wheel stops spinning because the patient needs to be readmitted?

This scenario plays out every day in America with seniors aging-in-place like never before. Staying at home has many advantages for both seniors and their insurance providers. The cost-saving benefits for both cannot be ignored. How do we keep it all in place so that it works well and provides excellent care for the senior aging-in-place?

Care Coordination Falls Short Of Expectations For Many Seniors

Issues arise when discharge plans get put in place without much input from other sources, namely the patient’s family. There are limitations on what any care provider can offer, based on what Medicare allows, making the balance between approved care and tailored discharge plans a challenging goal to reach.

We spoke to one woman who painfully told us the story of her mother’s rehab stay and the discharge plans that followed:

“My mother wound up in a rehabilitation facility after she fell at home and spent a week in the hospital. She was so weak that she couldn’t walk without assistance. The problem arose when my mother became non-compliant with her rehab treatment, so they told me they were discharging her home with PT to come twice a week to her apartment. This created an issue for our family as we were told Medicare wouldn’t pay for an ambulance to take her home and we couldn’t get her up to her second-floor apartment without any equipment to do so. She couldn’t walk down a hallway; nevermind climb a flight of stairs. We were at a loss. No one at the rehab knew what tell us to do…”

She cited a lack of communication with the family and coordination with other care sources as the reason for the debacle. How did she get her mother home?

“We borrowed someone’s wheelchair, and my brother and nephew carried her upstairs in it. We were so nervous that someone would get hurt, but no one knew how to help us.”

These kinds of stories are common in families with aging family members. Many readmissions and injuries can be avoided with better care coordination. Being able to communicate with a variety of service providers in real-time has been the roadblock to providing excellent care coordination and appropriate discharge planning. How can Medicare know what to provide for better patient care if there seems to be no comprehensive way to collect the data and provide it to them?

Care Coordination Is About Communication And Holistic Planning

The creation of workflow around mind sharing between care providers will prove to be useful as the concept of aging-at-home comes to maturity. Technology will play more of a role in care coordination, patient monitoring, discharge plans, and patient status evaluation. The future of care of the aging will rely heavily on technological advancement to making aging-in-place a safe and fiscally responsible thing to do.

Imagine a world where all care providers, medical professionals, and specialists could meet on one platform to make accurate care coordination a reality? What would be like if there was an EHR agnostic system that both worked within given workflows and could communicate outside of closed record systems?

There is such a solution poised to provide real care coordination between service providers and insurance providers. That solution is eCare Vault. With eCare Vault, all members of the care team, including the patient’s family members, can meet in one place on a HIPAA compliant cloud-based solution.

These tips are just a few of the ways that care coordination plays in enabling better outcomes for patients, but for your physician group or health system see real value and ROI for your care coordination efforts.

Is your health system or physician group struggling to implement successful care coordination strategies? Have you started but are finding that your efforts are fruitless thus far? Don’t fret - we’re here to help.

Download your free copy of The Ultimate Guide to Care Coordination and learn all the basics, the benefits of care coordination, the increase in revenue your organization will see, and how it will help provide better care for your patients.

Thank you for sharing!