Hospitals, Patient Engagement

Care coordination needs playbooks for complex care

Care teams must follow a playbook like the best football teams when providing complex care, writes the CEO and co-founder of, a digital health company.

NFl football photo courtesy of Flickr user ElvertBarnes

My mind has already turned to football season. I’m looking forward to getting together with family and friends, sharing loud and suspenseful moments watching the games, and of course, the snacks that complete the experience, which in my house are buffalo wings and big bowls of chips. It’s always invigorating to see incredible athletes compete on the field of play.

Just as with Olympians, these players spend a significant portion of their lives dedicated to the game, training to be the biggest, the fastest, the strongest. Going into game day, players and their coaches approach each match-up with a defined playbook that they want to execute to succeed. Of course, regardless of the preparation and training, in every game teams must quickly adapt these plans to the unexpected obstacles that inevitably arise.

Just like in football, care teams have a playbook.

My team and I are inspired by the efforts of care teams to overcome the challenges and obstacles of caring for patients with serious illness. We’ve learned a lot about the plays they run and how they carry out collaborative approaches to managing complex care, complex processes, and complex formations on the field.

The best efforts are centered around patients, and we see four questions which commonly define how strong teams overcome barriers to effective team-based care coordination. These are the questions they ask for each patient:

  • What is the plan?
  • What is the the state of play?  
  • How do we need to adjust the plan to achieve our goal?
  • How do we work together, leveraging the power of the whole team?

Answering these questions helps care teams get the job done on behalf of patients who need the most help – complex patients with the highest level of need and the highest level of risk. The answers to these questions change over time, so the whole team must be on the same page looking at the same information, with awareness and understanding of what that means to each person on the care team. This is how they stay in formation, no matter the challenge.

Strong execution across the continuum of care requires the right answers to these four questions.

What is the plan?

We’ve said before that the patient’s plan of care is the most important document in healthcare. This plan contains the contextual, relevant, and actionable information that a patient’s care team must know in order to accomplish anything. When everyone is aware of the role they play, and what direction the team is headed in, care teams make great strides. Key components include:

  • Patient preferences, functional/lifestyle goals, and treatment goals
  • Assessment of potential barriers to meeting goals, and related strategies
  • Care team members’ responsibilities, including the patient and family and all care team members spanning the continuum and the community
  • Medical summary with current problems, medications, allergies, among other things.
  • Emergency crisis plan

What is the state of play?

Too often, it’s challenging for the care team to understand the status of care, and new care team members aren’t able to easily come up to speed on the patient’s care plan. The plan must be activated across the team, reflecting its dynamic and changing nature. It must be presented in plain language, and data must be structured so that team members can digest it quickly and take action when needed. The patient and family must have access. These are key components for what we call the Care Coordination Record, as we’ve shared here on MedCity in the past.

How do we adjust the plan to achieve our goal?

Complexity is the norm for patients with serious illness, and there is a great deal of variation in how these patients individually respond to any given intervention. The complexity is heightened by the number of people involved in the care team and the volume of information and data they consume and create in the course of doing their jobs. When care teams operate in sync, they are able to respond in real-time to changes in patient status and more quickly adapt to unexpected obstacles directly in front of them. While we would love to imagine that today’s systems of care are as responsive as what I’ve just described, we don’t see many succeeding in practice without advanced care coordination technology that powers successful team-based care.

How do we work together, leveraging the power of the whole team?

In addition to using the right technology, the best teams have instituted rules of engagement that work to align each of the moving parts in a patient’s care plan and ensure that everyone is on the same page. This model for teamwork must transcend the four walls of the clinic, and for complex patients this model must work to make sure the right things happen across the patient’s care continuum and community. Nothing can fall through the cracks.

These four questions have been imperative in our quest to help those with serious illness. I know that buffalo wings and potato chips don’t serve my healthcare analogy well here, but the concept of a playbook that can help a great team successfully make health happen in their communities, against all odds – that concept will continue to inspire us. This is how we can help new healthcare models succeed in achieving better outcomes and economics with people-centered care.

Now, who’s ready for some football?

Photo Credit : Flickr user ElvertBarnes