MedCity Influencers, Hospitals, Patient Engagement

The importance of care coordination

While providers diagnose and treat in the hospital, care coordinators go beyond the four walls of that facility, into the community, and meet patients where they are, both literally and figuratively.

Some may ask the question, “What does a care coordinator do for my personal well-being?” There is no short answer as to what a patient can benefit from by receiving assistance from a care coordinator. Their job is to connect with high-risk individuals to uncover and identify needs in a patient-centered manner and in a way that takes into account whether the patient has endured any trauma.

When people think of care coordination, they typically think of improving one’s health by getting them connected with medical services. What care coordination truly is, is an incredibly intensive, wrap-around approach where you address all of the person’s needs ranging from medical needs to social determinants of health needs. They have the responsibility of rapport building over extended periods of time, having consistent communication and follow-up – meaning “showing up” for the patient population being served.

Care coordinators need to bridge gaps and connect silos among care team members and outsourced services. The work requires massive amounts of collaboration, coordination, sharing of data, member tracking and detail-oriented note-taking. Strength-based, patient-centered, and trauma-informed care are all critical to moving that needle. Now how is that all possible? Necessary technology.

Care coordinators days are usually unpredictable because we are dealing with people first, and systems/machines second. Care coordinators need specific tools and resources in their toolbox to succeed in this type of environment. Most days you are piecing the puzzle together to paint a picture of what is actively happening in a person’s life. Collaboration is critical to being successful.

Patients are assigned on a daily basis and care coordinators are in charge of exhausting all efforts regarding different forms of outreach in order to establish a connection, which includes house visits. The process is invasive and uncomfortable for both parties, but often a requirement so that care coordinators can confirm no stone was left unturned when attempting to contact the patient. These unexpected visits open up an entire layer of uncertainty, nervousness, and quite frankly, not knowing what could be going on behind closed doors, especially if alone (which is usually the case).

When I first became a Medicaid care coordinator I was aware of most of the socially unmet needs that marginalized populations faced, both in healthcare and in society. What I wasn’t aware of is how fragmented the healthcare system is as a whole. We’re not able to come together and wrap our arms around these patients because of limitations we have around data sharing, integrating with other systems, and not having the right tools in our toolbox to do this effectively.

The information care coordinators first receive when trying to connect with a patient is often sparse at best, which unfortunately leaves care coordinators uninformed. Care coordinators are asking a member to re-explain their story and to relive any traumatic experiences they may need to disclose to have the best care possible. On the flip side of that, care coordinators can leave appointments knowing so little about a member because they choose not to disclose this information, which is their right.

From my personal experience, a prime example of patients withholding information, although they have the right to do so, is when I went to another individual’s house that was on a TPS visa. We spent the first hour talking about his story, what services he currently has and what he needed. I noticed my hospital’s magnet on the fridge, with a coworker’s name written on the magnet, labeled “case manager.” I asked if he was working with us already, and he said, “oh yeah, that’s my case manager, she brings me food and cleans up my house!” Only after an hour of talking about setting him up with a home health aide and delivered meals, did I find out he was already getting this – meaning I would have been duplicating services.

How nice would it have been for us to spend that hour addressing other needs, such as housing or the lack of heating in his home? How impactful would it have been for me to actually bring the case manager with me so we could both be there at the same time? Asking individuals to start from scratch to tell us about who they are, with only 1-2 hours to get the necessary information, is not a good use of time. There has got to be a better way. Imagine if care coordination programs could integrate with these siloed systems and pull in data from them? If so, my current organization’s case management side would spend less time trying to track down patients because we would have visibility into other systems or services that they are utilizing.

Collaborating with other organizations that spearhead certain issues is very important — for instance,  with behavioral health case managers, nurses or professionals in similar roles. The work truly takes a community and by collaborating with leaders within the healthcare space, more complex needs can be met. All parties must be on the same page and be fully aware of what is actively occurring. 

Referrals are absolutely critical to getting patient needs met. Closed-loop referral systems can take away administrative tasks so that you get more time to actually work with the patient. Case managers are flying blind without pertinent patient information. They only know what they know, which is so little. They are working in communities and often times can get put in unsafe situations because necessary information about a person’s history is neglected. Being informed is not to pass judgment but allows coordinators to provide the most appropriate care.

Patient-centered care plan is proven to be the most successful in the long run. This means letting the patient be the captain of their own ship, while helping them navigate. Some SDOH programs allow the patient to be an active participant in their care plan and let them engage and communicate with their care team in a HIPAA compliant way.

Healthcare is already confusing for even the most educated persons. Imagine having multiple chronic conditions while also being below the federal poverty level. This patient population is usually in survival mode and concerned about the next meal or living situation. This means addressing their social determinants of health (SDOH) needs is absolutely essential to even begin addressing their medical needs. Social determinants of health are health, economic, and social conditions that influence one’s health status and is when care coordinators come in.

While providers diagnose and treat in the hospital, care coordinators go beyond the four walls of that facility, into the community, and meet patients where they are, both literally and figuratively. Case managers address unmet social needs that are preventing them from getting their medical care and having a good quality of life.

Care coordinators need to have the technological capability to connect with a member in other HIPAA compliant ways than just phone calls. Some of those healthcare technology programs give that option by allowing you to communicate with the member through the actual care plan itself. Case managers know the more appropriate people involved, the higher chance their patient has at successfully meeting their needs.

Photo: manop1984, Getty Images


Brooke Sabia is a Junior Account Manager, ActivateCare. Sabia graduated from UMass Amherst in 2016 with her degree in Sociology and minor in Women, gender & sexuality studies. Upon graduation she started in the field of corrections as a Female Services Counselor at MCI - Framingham. There, she facilitated groups on cognitive and behavioral skills, and had a caseload of up to 30 women that she created care plans for, in relation to their plans upon release. After leaving the MCI - Framingham, Brooke worked at Boston Senior Home Care as a Long-Term Services and Supports Medicaid care coordinator. Brooke’s role brought her into the community to engage high risk, medically complex children and adults and address their social determinants of health needs. While she was there, her program utilized Activate Care’s technology to track her caseload. After 2 years of direct care coordination, Brooke transitioned to Activate Care’s team where she is now a junior account manager, learning about similar programs across the county that may benefit from their direct care programs. Brooke currently lives in Boston with her partner, and their cat, Pebbles.

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