Minimizing the Dangers and Costs of Fragmentation In Care with Coordinated Care Models
Patient Story: Mrs. F
Mrs. F is a 60-year-old woman with diabetes and severe osteoporosis. She spends most of her time bedridden, uses a walking frame to walk, and has moderate memory problems. Her PCP prescribes her multiple medications but she also sees several specialists who are not affiliated with her PCP.
One day, Mrs. F’s home health aide finds her passed out on the floor of her apartment and calls an ambulance. At the emergency department, the admitting physician asks Mrs. F which medications she is taking, but she has trouble recalling. An attending physician on the hospital team contacts Mrs. F’s PCP, who gives a medical history and a list of medications she has prescribed her. However, she notes that Mrs. F has seen several specialists recently and that she may have received different medications. Mrs. F’s PCP is not in communication with the specialists and is not able to provide the attending physician with the changes to Mrs. F’s medications. Unable to locate the remainder of Mrs. F’s records, the physician prescribes a new medication that could potentially counteract the medications Mrs. F’s is already taking.
The case of Mrs. F is not an uncommon one. Over the last ten years, healthcare organizations and community partners have developed a greater understanding of the implications of a fragmented care system. For patients, fragmentation in care coordination poses significant risks to their health. For healthcare organizations, fragmentation in care results in higher costs. Patients and healthcare organizations can all benefit from a synced system of care.
Care coordination is “the deliberate organization of patient care activities between two or more participants involved in a patient's care to facilitate the appropriate delivery of healthcare services.” A coordinated system of care means that healthcare organizations and community partners are all working together to deliver consistent and appropriate care. By working together and maintaining clear channels of communication, every provider and community partner involved in a patient’s care is aware of the patient’s medical history, their preferences ,and needs.
The goal of care coordination is to improve healthcare outcomes for patients and to reduce costs by decreasing avoidable hospital readmissions and unnecessary treatments and procedures.
The Consequences of A Fragmented Care Model
Patients regularly encounter fragmented systems of care and the results often lead to unmet social needs, conflicting medications, incorrect dosages etc. Many of patients that are the most affected by fragmented care coordination are populations that are already at-risk for chronic illnesses and have an array of unmet social needs. In one study, researchers found that patients whose PCPs exhibited fragmented care coordination, were more likely to suffer from chronic illnesses like diabetes and hypertension than patients whose PCPs were more coordinated.
The same study also found that at-risk patients who experienced higher percentages of gaps in care coordination had higher rates of ambulatory care-sensitive hospitalizations than patients who experienced low percentages of gaps in care coordination. The patients of PCPs that exhibited fragmented care coordination also had a greater number of primary care visits in a given year as well as more specialist visits. Researchers also found that the costs of care associated with patients that experience the greatest fragmentation are higher than those who experience less fragmentation in care coordination. Patients who experienced the most fragmentation in care had an average total cost of $10,396, while patients who experienced the least fragmentation in care had an average total cost of $5,854.
Improving Care Coordination
Fragmentation in care is a result of many different factors, particularly outdated or limited use of electronic records and independent practices that have little communication with other healthcare organizations and community partners. Providers and community partners can improve communication between each other by implementing a tracking system that can manage referrals or transitions and allows organizations to “close-the-loop” in a network comprised of key partners. By implementing and improving care coordination models, healthcare organizations and community partners are one step closer to ensuring that patients receive holistic, quality care.
Healthify’s solutions can help reduce fragmentation in care by offering a platform in which healthcare organizations can assess a patients’ social determinants of health, search for appropriate care and refer and coordinate care with other providers and community partners. Our Partnerships team works directly with each organization to build a network of community-based organizations and then help deploy the product to coordinate referrals electronically.
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