What does care coordination look like in Public Health?

The Agency for Healthcare Research and Quality (AHRQ) describes care coordination as “deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care.” In the strict sense, it is not something that occurs exclusively in as from itself. Instead, it is a relationship that factors in different stakeholders in the health sector.

This relationship also presupposes some functional systems to facilitate the implementation. The interplay of each of them is complex, and at times handling it from its unity can result in abstractions that might not apply to specific situations. Being precedes action, but it is through action that we know being. Public health precedes care coordination, but care coordination can help us understand a functional public health system. Of course, we’re not interested in arguments among existentialists regarding essence and existence. We are attempting to lay bare care coordination in the entire arc of public health.

Charles-Edward Amory Winslow defines public health as ‘the science and art of preventing disease, prolonging life, and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals.’ It involves several activities done by society to ensure everyone lives a healthy life. It is public because it is not limited to individuals but involves an organized community effort, while the health aspect has to do with its mission of complete well-being.

The definition not only portrays its explicit injunction but also highlights the availability of essential activities that act as guidelines for public health. The federal government, states, and local health departments in the US are responsible for ensuring healthy lifestyles under the constitution.

These health systems have many channels for information and coordinated activity among them.

There are different ways through which care coordination can be implemented in the care continuum. The New England Journal of Medicine gives three ways and how they can strengthen care. First, in the primary care coordinated approach, a Registered Nurse (RN) coordinates with a primary care provider and any specialty providers to ensure adherence to the care plan. The model has been proven effective in reducing the overall cost of care, especially for those with chronic conditions.

The second is acute care coordination, which works best for patients in a critical or emergent healthcare condition and mainly consists in streamlining communication. But, of course, the coordination does not end once the emergency has passed. Acute care coordinators confirm proper transition of care by scheduling follow-up visits and other services like transportation and housing, making sure prescription medications are filled at the patient’s pharmacy and either picked up for the patient or delivered to the patient, and reviewing follow-up instructions with the patient and their family or loved ones.

The third way is called post-acute or long-term care coordination which mainly applies to patients who reside in rehabilitation or require long-term care facilities. The three models do not call for privileged or fragmented care when dealing with specific subsets of patients. Instead, care coordination uses a holistic approach, and such models help everyone understand the care plan and related expectations. Therefore, special care is needed in their implementation in the public health systems.  

An opinion poll by Robert Wood Johnson Foundation (RWJF) on the public’s perspective about the nation’s public health system at the federal, state, and local levels during the COVID-19 pandemic contains insights that can help in addressing the issue of care coordination. The survey showed serious concerns about the functioning of the public health system. The public lacked trust in essential public health institutions to address todays and future challenges. In addition, the level of trust among healthcare workers was higher than that of US public health institutions and agencies for recommendations to improve health.

Although some criticized the opinion poll, like all the other COVID measures that appeared to be politically biased, the information helps make certain decisions. Of course, there is no such thing as pure objectivity where man is involved, but it is only by approaching a subject from different angles that we can answer specific questions.

The opinion poll has an upside and downside. The upside is that at least the trust among healthcare workers, the key players in care coordination, still exists. The downside is that a lack of confidence in the public health system can hinder the implementation of even those potentially beneficial policies.   

Different stakeholders have had varied ways of improving care coordination in public health. However, technology has been highly featured in most of the interventions. For example, in the case of the care coordination IT vendor Audacious Inquiry, their flagship solution, Encounter Notification Service (ENS), has enabled more than 215 hospitals in Florida to share data to improve care coordination and quality of care, thereby reducing potentially preventable visits and lowering costs.

A key advantage ENS has in care coordination is the provision of real-time data when patients encounter acute care facilities to subscribing health systems, health plans, accountable care organizations, community health centers, and physician practices, regardless of the electronic health record system being used at each facility.

Such a huge database has helped identify the location and reasons for potentially preventable visit encounters and the exact timing of the encounters to monitor trends. It not only serves inpatients but also provides notifications to enable successful transitions from facility to home, assessment for social determinants of health, and follow-up with the provider in the outpatient setting.

Talking about care coordination without backing on Medicaid can be an injustice on the topic. In the United States, approximately 33% of adults and 13% of children enrolled in Medicaid insurance programs report barriers to finding a doctor or delays in receiving care despite having a usual place of care. The barriers have resulted in Medicaid enrollees using Emergency Department (ED) 6 to 7 times more often than privately insured patients.

To resolve the enigma, the ED Navigator Program was created in March 2018 by Mass General Brigham (MGB), Harvard’s main hospital in Boston. Since its creation, there have been positive results with the potential of changing the care coordination space, especially in the Medicaid ACO population.

For instance, a study that looked at care coordination using a model that involved ED patient navigation showed promising results that can help reduce ED visits in those with low baseline ED utilization. The program engaged community health workers to promote primary care engagement, facilitate care coordination, and identify and address patients’ health-related social needs. The study also demonstrated that ‘ED navigator encounters were significantly associated with increased rates of follow-up with primary care among a Medicaid ACO patient population.’

The push toward managed care and value-based payments has also led to increased care coordination in the public health space. Almost 9 in 10 acute care hospitals can send patient information to sources outside their health system. Additionally, more than 6 in 10 can integrate a summary record of outside care. The data exchange has enabled tech-enabled care coordination among patients, providers, and care teams.

This has also been a push factor for innovation, with companies such as Landmark Health innovating services that combine technology and human intervention to address the complex care needs of Medicare Advantage Patients. For example, Landmark has a remote monitoring technology to ‘help providers decide when it is worth making a home visit to a patient with complex medical and behavioral issues, as well as whether a nurse, a doctor or a social worker should be dispatched.’

The interplay of care coordination and public health is proof that we cannot embrace given realities in one form of a statement. On the contrary, we glimpse different aspects from different sides, which cannot be traced back to each other. The two need to be taken together as a provisional assessment of the whole, which is not accessible to us as a unified whole because of the restrictions implicit in our point of view.

The high rate at which different institutions implement care coordination across various public health systems looks promising. Some are already enjoying the benefits, but it also comes with a few challenges that need to be addressed. Nevertheless, the is clinching proof that the benefits are more than the risks, and we cannot afford to ignore this noble measure of attaining effective healthcare in many healthcare systems worldwide.