Care Coordination plays a very important role in providing quality care to senior patients, especially those living with a chronic illness. It can mean fewer emergency room visits, reduced hospital readmissions, lower cost to appointment co-pays, easier access to medication, a lower mortality rate, and higher quality of life.
Though care coordination is not always on the top of mind when considering senior care, it should be. A George Mason University survey of 1,500 senior communities found that 78 percent coordinate treatment with at least one third-party provider. There are many moving parts when it comes to caring for seniors. When the medical care provided to a senior patient is disjointed and lacks the proper communication among those involved, information gets lost and resources are left unutilized.
What is Care Coordination?
According to The Agency for Healthcare Research and Quality (AHRQ), “care coordination deliberately involves organizing activities for patient care and sharing every information among all participants concerned with a patient's care. Hence, achieving a safer and more effective care delivery service.”
A wide variety of resources fall under the care coordination umbrella. Care coordination can often be personalized to meet the patient’s specific needs and to prevent them from slipping through the cracks.
Resources made available through care coordination management systems can be found all in one place, including:
- Primary care management services
- Transportation
- Meals
- Gym memberships
- Social support services
- Access to x-rays and ultrasounds
- Eye appointments
- Dental care
- Dialysis
- Hospice care
- Diabetes management
- Medication refills
- Cost management
- Appointment coordination
- Tailored health plans
Care coordination means a team of dedicated professionals, all collaborating to provide the best possible care to patients.
1 Strategy
Care coordination involves strategizing of care plans for individual patients, identifying potential gaps in the resources available to patients, and risk-management within the senior community (such as isolation and COVID-19).
2 Targeting
Care coordination can help identify high-risk patients and intervene on multiple levels of the medical system, with a holistic approach that keeps all parties involved in the loop.
3 Prevention
Care coordination encourages and empowers the patient to self-manage their care, with all of their needs being met within one system. It also gives an interdisciplinary care team all of the information necessary to assist in preventative medicine.
Who is Involved in Care Coordination?
Care coordination is a complex process that very literally requires a team of healthcare professionals coordinating together to ensure that their patient is receiving the best possible care.
An ideal care coordination model usually involves the following:
- A director: The head of the care coordination team is often a qualified nurse or social worker who guides a team of professionals in communicating and staying connected.
- An assessment: When beginning care coordination, seniors' needs are being monitored from day one. This can mean taking a look at the patient’s general health, mobility, and memory, all to create an individualized plan and to determine the best course of action.
- A care plan: A care plan should detail what was found in the assessment and should outline what resources are going to be made available to better the quality of the patient’s life. Outlining these services ahead of time will keep everyone involved in the know of that specific patient’s needs.
- A medical team: An interdisciplinary care team will be collaborating to better care for the patient. This can start with the primary care provider but can include specialists, physical therapists, and mental health professionals.
- Communication with insurance companies: Care coordination is about bettering the lives of patients, and this means having the team working more directly with insurance, medicare, and Medicaid to ensure coverage.
- Consistent monitoring: Remote patient monitoring allows for health organizations to stay connected with the patient between visits.
Care coordination should be flexible, and will strategically shape around the patient’s ever-fluctuating needs. Assessments should be referred back to and care plans can be updated based on results and data.
How does Care Coordination Affect Seniors?
Seniors regularly suffer from isolation, a lack of resources, and a lack of transportation. They often are required to live without a strong support system, or at best may be guided by younger family members that aren’t going to have all of the answers when it comes to healthcare. They are shuffled from one appointment to the next and must remember and keep track of all of the information being given to them concerning their health and their very livelihood.
Care coordination provides that support system that is lacking in a senior patient’s life. They are provided with tools that make managing their health a more attainable task, with a team of people that are making it a priority to stay connected, communicate, and improve the patient’s quality of life.
When preventative care is made a focus, health issues are less likely to progress. This of course means healthier patients!
Why does Better Care Coordination Mean Fewer Emergency Room Visits?
A team of connected health professionals, all collaborating to keep the patient healthy and resources made available to the patient to help better manage their health all work in favor of a life with fewer emergency room visits and hospital readmissions.
For example, if a senior struggle with diabetes, a community dedicated to helping that senior keep their condition in check will mean that it doesn’t progress to emergency status.
1 Team Collaboration to Avoid Emergency Room Visits
When primary care providers, specialists, and those managing the seniors’ life (whether that be the individual or a community), all have access to the same information, that’s going to lead to better long-term decisions for the patient’s health.
2 Resources to Avoid Emergency Room Visits
Resources like rides to medical appointments, communities to alleviate senior isolation, access to meals, and readily available information about a healthy lifestyle all contribute to empowering seniors to take control of their health and make avoiding the emergency room a less daunting task.
How can Senior Communities Better Their Care Coordination?
It’s important to remember that care coordination can be implemented in many different ways, but it can be optimized by a management system. Rainbow Health is dedicated to providing individualized care-in-home management platforms.
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