March 22, 2018 | Sherry Dillon, RN, CPHRM
What does “coordinated care” mean?
In-Network. Population Health. Care Coordination. These are all buzz words in healthcare. Well-intentioned directives to help solve the most pervasive—and often problematic—challenges for hospitals, physicians, payors, and patients.
When patients are referred to specialty physicians out-of-network and care is not properly coordinated from the hospital system to other providers, the leakage rate can be detrimental to an organization’s revenue. While the financial impact can be millions of dollars lost, the impact on the patient downstream is even greater. Poor care coordination leads to sub-optimal outcomes, a slow recovery, complications, readmissions/revisits, or at worst—further injury to the patient.
Payors are also impacted. Costs escalate when the patient doesn’t make it to the optimal level of care at the right time.
Physicians feel frustration with complex care coordination process as they try to ensure the patient gets the follow-up care they needed. Efficiency is important to physicians. Overly complex processes to coordinate appropriate referrals get in the way of ensuring the optimal specialist is referred.
While legislators, hospitals, payors, and other key stakeholders focus on care coordination from the inpatient setting, the emergency department (ED) is often overlooked. It’s not necessarily surprising, since the ED is such a difficult place to tackle these problems. It’s a high risk, high volume, problematic setting in which a lot of leakage occurs. Approximately 80 percent of patients that come to the ED are discharged to home and left to recover independently. Most of these patients never follow-up with a specialist or primary care physician.
The ED is actually the ideal place to start tackling the problem of care coordination. ED research would not only bolster national efforts to improve care coordination and keep patients in-network, but also play an instrumental role in improving the patient experience and optimizing outcomes.
Two primary challenges keep hospital administrators from tackling leakage in the ED: The Emergency Medical Treatment and Labor Act (EMTALA) and on-call physician specialist consults.
EMTALA requires an ED physician do what’s necessary to ensure the patient is stable; which may include contacting a specialist consult to help determine patient stability. EMTALA requirements are satisfied once the patient is deemed stable. For patients discharged to home, the specialist consult used to help stabilize the patient is often provided as the referral physician for follow-up. However, in situations where the specialist consult did not establish a patient-physician relationship—or was not needed for the ED physician to stabilize the patient—but the patient requires a follow-up referral, the ED physician naturally goes to the on-call specialist for referral, or it’s required by the organization’s Medical Staff Bylaws for the on-call referral specialist to follow-up. This works when the on-call physician is also in the organization’s network, but not so well when they are out-of-network.
If you’re thinking about best practices for care coordination in the ED, start by ensuring your Medical Staff Bylaws account for on-call specialist processes. Try to streamline processes to enable ED physicians to easily select an in-network specialist. Incorporate high-tech solutions to make the process easier, as well as track compliance.
In addition to practical solutions, tracking performance around referral management compliance, sharing results, and understanding systemic trends for rapid cycle improvement strategies is critical to ongoing compliance and success.
Optimizing referral management in the ED is certainly a step in the right direction for care coordination efforts. Helping the patient easily navigate the complex healthcare system and manage their care both helps the patient transition care settings smoothly and reduces the likelihood of exacerbated chronic conditions. Looking through the lenses of population health, care coordination is one of the essential pillars to ensure that every patient receives a high quality discharge.