The Winding Road to Value
The journey to value for U.S. healthcare, however winding, is likely to continue if for no other reason than mounting pressures on both the Medicare trust fund and U.S. global competitiveness dictate that it must.
For health systems this means that affiliated provider networks initially assembled to source referrals for hospital-provided services will increasingly be tasked with managing population risk. To safely do so requires a comprehensive care delivery network with high operational integrity.
Accordingly, leading health systems have been increasing their investments in comprehensive care coordination programs yet often struggle to cost-effectively scale these programs due to logistics related challenges. Complexity of choice within a care delivery ecosystem increases geometrically with scale and the logistical barrier is one which health systems must overcome to advance to the next level.
To Coordinate first you must Connect
Care Continuity defines a care delivery network with high operational integrity as one with mechanisms in place to ensure patients receive timely care from the appropriate network-aligned providers and to provide seamless transitions of care along the span of the patient journey.
In contrast, the Agency for Healthcare Research and Quality’s (AHRQ) definition of care coordination is: “Deliberately organizing patient care activities and sharing information among all the participants concerned with a patient’s care to achieve safer and more effective care.”
While these two concepts are closely related, they are not interchangeable. AHRQ defines care coordination as a clinical function typically performed by registered nurse (RN) care managers, working in collaboration with physicians focused on orchestrating patient care activities in adherence with evidence-based clinical protocols. In this sense, care coordination is part of the core clinical mission.
Conversely, the network navigation related activities required to attain operational integrity within the aligned care delivery network are non-clinical in nature.Appointment setting, scheduling transportation, tracking referrals, providing records, checking on lab results…all vitally important for the smooth flow of patients and information across the network yet none of which involve clinical decision making.
In short, network navigation is mission support.
Unpacking the Network Navigation (Care Logistics Management) Challenge
The distinction between these two functions is critical as it explains why health systems and health plans routinely struggle to scale their care coordination programs. Too often, investments are made in the clinical staff and systems needed to coordinate patient care while neglecting the supporting care logistics infrastructure needed to effectively connect patients to the aligned care delivery network.
As an example, let’s review a patient discharged from an emergency department (ED) requiring follow-up care from a specialist. Each of the variables listed below must be taken into consideration when navigating the patient to the appropriate provider:
- Clinical needs – what are the specific needs of the patient in terms of specialty and timing?
- Patient preferences – does the patient have a preferred physician to see? What are their preferences for locations, days of the week, physician attributes, etc.?
- Patient constraints – does the patient lack transportation or any other social determinants of health (SDOH) needs to be addressed?
- Existing patient-provider relationships – are there existing patient-physician relationships to be taken into consideration?
- Primary Care Physician (PCP) referral preferences – does the patient have an established PCP that has any preferences for specialists preferred?
- Insurance related constraints – does the patient’s insurance require a PCP referral for a specialist visit? Do they have coverage that limits their access choices?
- Accountable Care Organization (ACO) involvement – is the patient covered by an ACO? If so, which providers are in the ACO’s narrow network? Are there specific notification and hand-off protocols that the ACO and hospital follow?
- Provider profile – network affiliation, specialty and sub-specialty, office hours, insurance accepted, pre-registration requirements, appointment reminders, practice hours, scheduling preferences…. the list goes on.
- Specialized programs – does the health system have any specialized programs that would benefit the patient?
- Miscellaneous – Are there gaps in care, incidental findings, VIP status, etc.?
Then we have provider selection, appointment scheduling, chart provisioning, referral coordination, transportation assistance, and confirming attendance and follow-up care requirements. It’s a lot.
The key point is that none of this has anything to do with clinical decision-making. Yet, if any of the variables are neglected there will be issues with the timeliness and effectiveness of the care received. Lack of proper management for transition of care could result in higher patient no-show rates, network outmigration, patient dissatisfaction, physician dissatisfaction – or, more likely, a combination of the above.
Now, consider these variables across multiple hospitals, several hundred thousand ED discharges, multiple ACO relationships, an aligned care delivery network consisting of thousands of providers and hundreds of practices with varying degrees of network affinity, and some idea of the overall complexity challenge emerges.
Layering in Network Navigation
Healthcare is the only industry that expects its customers (patients) and its professionals (clinicians) to manage basic execution logistics. Without the proper logistical support, the burden falls on either the practices, RN care coordinators, or the patients. The practices have neither the staff nor the systems to do it. The RN care coordinators rarely have the required supporting technology and furthermore, are not working at top of license. Too often it falls to the patients, and they simply do not have the tools to successfully self-navigate today’s complex care delivery ecosystems.
The bottom line is this: you cannot cost-effectively scale clinical care coordination programs without a supporting care logistics management infrastructure consisting of the right technology combined with network navigators (Care Concierges) tasked with supporting both the patients as they journey across the network and the members of the patient-centered care team providing the care.
Conversely, with the right support from network navigators, physicians and RN care coordinators can focus on care delivery, secure in the knowledge that logistical challenges aren’t going to interrupt the continuity of care. Everything just works the way that it should.
One last point: network navigation is almost always financially self-sustaining. The reduction in forced network outmigration (leakage) improves the overall share of care for the health system. On average, every $1 spent on care logistics management results in $4 in additional near-term (120-day) contribution margin – all while providing better care for the patients.
Want to learn more? Register for the next webinar in our series, “Want to Increase Utilization? Understand Why Patients Leave Your Network,” HERE. View our most recent On-Demand webinar, HERE. Ready to talk with an expert and see a demo? Schedule a meeting with us today.
