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How to Provide Coordinated Care Plans to Patients

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Care coordination services for healthcare patients involves organizing patient care activities between the patient and their healthcare team, through managing the necessary resources and proper providers to deliver essential care.  Within large healthcare organizations, in which patients may interact with multiple staff members, including providers, receptionists, and even students or interns, providing coordinated care can be a complicated process.  

The overall benefit of care coordination is meeting the needs of your patient while also providing high-quality care.  Coordinating care for clients is multifaceted and requires effort from the entire care team.  Not only should patients have easy access to their providers, but internal communication and goals between providers should be aligned.  The focus of providers must be on providing quality care to patients, through proper internal coordination and planning, as well as clear and simple external communication with patients. 

The Triple Aim of Coordinated Care

In 2007, the Institute for Healthcare Improvement developed the “Triple Aim” of healthcare in order to optimize the performance and quality of care provided by healthcare organizations.  Implementing the strategies in the triple aim model will not only improve patient health outcomes but streamline the care you provide to patients within your organization.  The Triple Aim includes:

  • Improving the patient experience of care

To improve patient experience, it’s crucial to analyze your target population properly.  This includes assessing the general health of the community they operate in and identifying areas of risk.  Aside from having a proper understanding of your target population, improving patient experience also includes implementing strategies to make navigating the healthcare system easier for clients.  This may mean introducing an EHR with a patient portal, where clients can more easily access their health information.  Research has shown that almost 75% of patients felt if they could access their health information online, they would have a better understanding of their health.

  • Improving the health of your target populations

Once you’ve identified the risk factors of your communities, your healthcare organization can work towards implementing initiatives that target those risk factors and problem areas, to improve community health.  Part of developing these initiatives aimed at alleviating the risk areas includes coming up with a care coordination strategy.  Putting this specific strategy in place will help provide individualized and effective care, therefore improving the overall health of the surrounding community.

  • Reducing the per capita cost of healthcare 

The US has the most expensive healthcare system in the world, at 17% of our gross domestic product (GDP).  The Triple Aim hopes to find strategies for reducing healthcare costs, while simultaneously improving the quality of American healthcare.  

Strategies for Providing Care Coordination Services

Achieving the triple aim within a healthcare system takes organization, collaboration, and coordination between providers, supervisors, and support staff.  Read through these strategies for ways to improve the care coordination services your team provides to their patients: 

1. Leverage an EHR to share patient information

When working with multiple practitioners to provide care to patients, sharing intake forms, chart notes, and assessments is crucial to care coordination.  A cloud-based, HIPAA-compliant EHR platform is the best way to keep patients’ information safe while still being easily accessible by each practitioner. Having access to the full scope of information allows each practitioner to make the most informed treatment decisions, and ensures clients receive high-quality care and have a positive care experience

Internally, EHRs can help coordinate care across the entire provider team.  It’s beneficial to have them in place when a colleague is out of office due to maternity leave, illness, or leave of absence and their clients are in need of coverage.  This allows for seamless continuity of care for the client.  Additionally, implementing an EHR has also been shown to positively impact an organization and its members.  Research has demonstrated that hospitals with EHR systems in place had a higher level of operational performance and increased provider satisfaction with their current practice and overall career.  

2. Build a comprehensive coordinated care plan for clients

In healthcare,coordinated care plans are being leveraged as a way to share wellness interventions with patients, in order to provide patients with constant access to recommendations from their provider in-between sessions. Coordinated care plans can include resources, goals, and next-steps for patients, all available in a format that allows them to understand complex recommendations and treatment protocols.  

Recording these recommendations allows health and wellness providers to review patient progress over a period of time, and reassess with patients at each appointment.  This allows for a more collaborative relationship and enables patients to take an active role in their own health.  Creating and sharing a Coordinated Care Plan post-session with patients is an effective way to reinforce the concepts discussed. Whether it’s a written summary of your treatment recommendations or additional resources for them to review, the care you give to your patient in session can continue afterward. 

3. Communicate your recommendations to patients and their care team

Another way to provide patient care coordination to patients is to ensure both patients and their care teams are on the same page about interventions and recommendations for their treatment.  When patients have a clear understanding of their treatment regiments and can discuss questions and concerns with providers, they are more likely to adhere to the treatment protocol. 

Communicating recommendations to the rest of your patient’s care team keeps them involved and up-to-date on your current treatment strategies, as well as patient progress.  It’s important that practitioners in a multi-provider team are communicative about patient recommendations, to ensure there are no contradictions.  All of the intervention strategies should work together to provide comprehensive and effective care for your patients.  

4. Organize a patient engagement strategy

Patient engagement means the ability to deliver care when patients most need it: in real-time. With advances in technology and telehealth, healthcare providers are able to work with patients in real-time by providing video calls and message support, monitoring patient progress through wearable fitness trackers, and delivering patient education electronically. 

When working on a team with multiple providers, it is important to coordinate a strategy for engaging with patients.  It can be overwhelming to patients if each provider they work with is checking in on them multiple times each week, asking similar questions, and providing similar recommendations.  Delegating engagement tasks to providers across the team avoids any overlap in communication with patients, effectively enforces recommendations, and keeps them clear for patients.  

For example, you can assign each provider on the team an area of engagement to focus on with the patients.  The dietitian can review patients’ food journals, while primary providers can check-in using a chat feature and review metrics.  Receptionists can reach out to patients for scheduling purposes, and supervisors can assess all of the patient’s data using the EHR and contact patients as they feel necessary.  With a clear strategy in place, each practitioner can focus on providing high-quality engagement in their focused area.

How to Use Healthie to Provide Care Coordination Services 

The Healthie platform allows practitioners to coordinate all aspects of patient care so that they can provide high quality and positive patient experiences.  Healthie has a variety of features to support your care strategy, including:

  • Cloud-based EHR: Healthie’s EHR feature allows providers to create and share chart notes and intake forms, and access patient information from anywhere.  The Healthie platform is HIPAA-compliant, so both providers and patients can be sure that personal health information is secure.  
  • Coordinated Care Plans: Within Healthie, you can easily create individualized care plans for patients, using data from chart notes, metrics, and goals already in your patient’s profile.  Make nutrition, activity, and custom recommendations, set goals, and track metrics. 
  • Patient engagement suite: The Healthie platform offers a host of engagement capabilities, including journaling, metrics tracking, secure chat, and telehealth appointments.  
  • Group practice features: Healthie’s organization features support multi-provider practices, through shared calendars, forms, and chart notes, group chat capabilities, and permission settings.

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