Why Care Coordination?
The American medical system is extraordinarily fragmented and difficult to navigate. The average Medicare patient sees seven different doctors, according to the New England Journal of Medicine, and patients with multiple chronic conditions may see up to 16 physicians annually. For 33 percent of patients, the assigned primary physician changes on a yearly basis. With well-coordinated patient-centered care, patients transition between providers easily, their preferences for care are respected, and their medical histories are available to each and every healthcare professional involved in their care. Unfortunately, poorly coordinated care often leads to medical errors, higher costs, and unnecessary pain for patients.
By 2020, an estimated 157 million Americans will be grappling with at least one chronic condition. These patients will require personalized attention and seamless transitions from one care setting to another – something the system currently does not provide. Instead, many patients suffer due to a lack of communication with or between providers. This communication void has dangerous and costly consequences - one in five patients discharged from hospitals experience an adverse event within thee weeks.
As a National Priority, the impact of well-coordinated care will reverberate across the Priorities. Increased communication between patients and providers, stronger record keeping, and more efficient, patient-centered care can reduce harm while making healthcare more reliable and accessible.
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Care Coordination in the New England Journal of Medicine
A 2009 study found that one in five Medicare beneficiaries discharged from the hospital was readmitted within 30 days, and half of non-surgical patients who were readmitted to the hospital within 30 days had not seen an outpatient doctor in follow-up. According to the study, unplanned rehospitalizations cost Medicare $17.4 billion in 2004.
"So far as rehospitalization is concerned, the National Priorities Partnership is right on in making care coordination a national priority," said the study’s lead author, Stephen Jencks, M.D., M.P.H. "If we want to prevent unplanned rehospitalizations, we have to help hospitals and community healthcare providers implement transition procedures that are more patient-centered. Medicare patients are very vulnerable when they leave a hospital, and care that is uncoordinated is unsafe. It is not a solution, it is part of the problem."
The study, “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” appears in the New England Journal of Medicine.
Focusing Care on the Patient for the Long-Run
The Partners are working to ensure that:
- Healthcare organizations and their staff will continually strive to improve care by soliciting and carefully considering feedback from all patients (and their families, when appropriate) regarding coordination of their care during transitions.
- Medication information will be clearly communicated to patients, family members, and the next healthcare professional and/or organization of care, and medications will be reconfirmed each time a patient experiences a transition in care.
- All healthcare organizations and their staff will work collaboratively with patients to reduce 30-day readmission rates.
- All healthcare organizations and their staff will work collaboratively with patients to reduce preventable emergency department visits.
Supporting Resources
- NYU ED Algorithm - The Center for Health and Public Service Research, New York University
Care Coordination in the News