Academic journal article Generations

Why Is Care Coordination So Difficult to Implement?

Academic journal article Generations

Why Is Care Coordination So Difficult to Implement?

Article excerpt

Part of the trouble is the fee-for-service systems' built-in care coordination redundancies.

The goal is a virtuous one: all care the "system" provides for a person with ongoing needs for support and medical intervention should be coordinated. Virtually everyone involved in providing any kind of care-clinical and administrative professionals in service-providing organizations, family members, consumer advocates, and policy makers-believes there are coordination problems. And each and every one, to a person, could tell chilling tales of the dangerous and wasteful results of poor care coordination.

One might think that people of goodwill (aren't we all?) should be able to sit down, system by system, neighborhood by neighborhood, and work this all out. But progress has been slow, incremental, and fragile. Policy makers in Medicare and Medicaid have tried to encourage comprehensive care coordination in a series of demonstrations and policy initiatives dating back to before the beginnings of On Lok (the original PACE demonstration program begun in San Francisco that launched in 1979). While there have been notable successes in specific locations, each model that has been deemed successful has hit barriers to broad implementation, or "scaling."

The essence of almost all strategies to improve health services for older persons and persons with disabilities, both medical care and long-term services and supports, rely on the concept of care coordination. As coordination programs are replicated around the country, numerous approaches are emerging-many demonstrating that finding the most efficient and effective way to coordinate care across the entire spectrum of care is not as easy to do as it is to talk about. This is an issue that has nettled policy makers for years. This article will explore, from a systems perspective, some of the reasons why coordinating care across the spectrum is so difficult.

Care Coordination in Medical Care

Failing a voluntary nationwide metamorphosis in how care is coordinated, the Patient Protection and Affordable Care Act (ACA) architects gave the Centers for Medicare & Medicaid Services (CMS) several new tools and considerable resources to implement broader care coordination. Through grants supporting innovations, CMS can entice players in the system to work together differently and creatively, and they will apply financial pressure, too, docking providers that lack of at least some care coordination. From Accountable Care Organizations (ACO) and their positive incentives, to reimbursement penalties for hospitals tied to higher-than-expected readmission rates, CMS has been moving on many fronts, all with an expectation of improving care coordination.

The common element in these approaches is to cluster care reimbursement in such a way as it imposes on the provider a new incentive (positive or negative) to coordinate care in their sphere, and, to some degree, with one or more other elements in the healthcare system. In the case of ACOs, the idea is to coordinate medical care across as many specialties as possible to avoid unnecessary care. When successful, the ACO retains a portion of what they have "saved" the system. With hospital readmission penalties, hospitals have to ensure coordination occurs between all parties when patients are discharged from the hospital to prevent holes in a plan of care that might cause unnecessary patient readmission. Both are forms of care coordination.

The ultimate form of care coordination comes with payment in the form of capitation strategies. These put a single entity at risk with broad areas of responsibility for providing care for individuals across a range of levels of need. In these situations, like Health Maintenance Organizations (HMO), the organization is strongly encouraged to effectively manage care. The challenge of managing care is directly related to the need for care, because payments are set at a level associated with the "average client" or enrollee in the program. …

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