Health care delivery is usually discussed in broad, dramatic strokes: open heart surgeries, organ transplants, cancer patient survival rates.But seemingly insignificant things can dramatically impact health care delivery. For example, a patient misses a crucial doctor’s appointment because they lack transportation, leading to another hospital stay. Or, a patient with diabetes lets their health slip to a dangerous level because of depression or denial, leading to an amputation or blindness.
Given the number of Americans with chronic health care conditions, these missed connections or lack of self-management add up quickly. They cost the U.S. health care system tens of billions of dollars a year. Most experts agree that if providers worked to better coordinate care and communication with patients, both their outcomes and overall health would improve.
Opportunities abound within the U.S. healthcare system to cut costs. A recent study by the Commonwealth Fund concluded that the United States spent $9,086 per resident in 2013 to deliver health care. That is nearly 50 percent higher than in Switzerland, the second-most expensive industrialized country in the world for health care.1 While an iPhone is priced much the same in Paris as in Chicago, it is fairly easy to guess in which city joint replacement surgeries are 10 or 20 times more costly.
When the Affordable Care Act (ACA) was enacted into law more than five years ago, it contained numerous provisions intended to push providers to better coordinate care in the hope of improving outcomes while cutting costs.Among the initiatives introduced by the ACA were: bundled payments for episodes of care such as joint replacement; initiatives to reduce infections patients acquire during their hospital stay; and an attempt to greatly improve the nation’s system of primary care. Perhaps most significantly, the ACA introduced a program that cuts Medicare payments to hospitals across the board if their patients are readmitted within 30 days of discharge.
One such initiative, undertaken by AtlantiCare (an affiliate of the Geisinger Health System in
Pennsylvania) decreased hospital admissions and hospital emergency room visits by 20 percent, and reduced the annual cost increase trend from 25 percent per year to about 4 percent.2
Bon Secours Virginia Medical Group used a mixture of education and direct phone lines to nurses to reduce the readmission rate for chronic heart failure patients below 2 percent.3
After an initial adjustment period, most patients are pleased to receive coordinated care. A recent poll by the SCAN Foundation about a program for treating Los Angeles County residents who are “dual-eligibles” (those enrolled in both Medicare and Medi-Cal/Medicaid and often being treated for multiple medical conditions), concluded that 77 percent of program enrollees were very satisfied or somewhat satisfied with the way their doctors were working together to provide their healthcare services.4
But in order for these initiatives to succeed, the close coordination of care by trained professionals is critical. Target patients for care coordination programs often have at least one chronic condition. Many lack a social support system that is crucial for ensuring they have transportation to medical appointments. They may also be battling ancillary conditions such as depression, which can make it difficult for them to stick to medication regimens or make the lifestyle changes crucial for ensuring improved health and fewer hospital admissions down the line. Among middle-aged whites who lack a college degree, their morbidity and mortality rates have been rising dramatically in recent years, suggesting an enormous challenge ahead for treating that particular group.5
Some care coordination is currently being provided by registered nurses, other by experienced laypersons such as promotoras. The latter are highly active and conscientious laypersons who live primarily in Latino communities throughout the western U.S. Although Kaiser Permanente employs promotoras for some of its care coordination programs in California and the Pacific Northwest, promotoras likely will not work in many parts of the country.
Meanwhile, the demand for nurses to perform clinical work is extraordinarily high, leaving in question whether they are the best point persons for care coordination.
“Everyone should be operating at the height of his or her license,” said Liga Mezaraups, Administrative Director of Care Transformation for Swedish Health Services, an operator of five hospitals in and around Seattle.
Swedish does employ nurses as ambulatory care managers who focus on patients near or at discharge from the hospital, or are receiving follow-up care in Swedish’s clinics. But the need for nurses elsewhere helped shrink the care manager team from ten to six in recent months.
Nevertheless, Mezaraups said Swedish needed to better focus on transitions of care and take into consideration the patient populations that are at “higher risks at the time of transition” because of issues that may never come up while they are hospitalized.
Enter the care coordinator – a non-nurse employee with some clinical experience who can better ensure that care is finely coordinated for vulnerable patients but who do not require a nursing or other clinical license in order to do so.
Swedish contracted with COPE Health Solutions earlier this year to begin the training of its first cohort of Care Coordination Scholars in its clinic settings. Eleven individuals were chosen for training. All of them were recruited from the Health Scholar program already in place at Swedish, although there are plans to expand recruitment in the near future.
The Care Coordination Scholars share common characteristics, including empathy, compassion, organization, and even a sense of humor— all of which help them to engage patients. They must also demonstrate a high degree of integrity, given their access to patient medical records. COPE Health Solutions developed the 16-hour training curriculum.
“The modules are very Swedish-specific; they’re built with their specific culture in mind,” said Leah Rosengaus, COPE Health Solution’s Director of Health Care Talent Innovations.
What makes a good care coordinator?
According to Rosengaus, most of Swedish’s first Care Coordination Scholar recruits have some sort of relevant medical experience, such as volunteering in a clinic or a hospital. Most intend to pursue either a medical or health care management career themselves – hence their prior participation in the Health Scholar program. All are nearing the end of their undergraduate studies or have just earned a degree.
The overall mission of care coordinators is to ensure a continuum of patient care by identifying potential barriers to needed medical services and promoting communication between themselves, patients and their providers to overcome those barriers. Care coordinators perform a variety of duties in order to achieve those goals. They include screening patients regarding their need for a care coordination; developing a plan of care with a patient’s primary care physician; facilitating medical appointments and communications between primary care and specialty providers; scheduling interpreter services for patients whose speak a language other than English; and documenting patient encounters.
Participants in the Care Coordination Scholar training program closely observe the work nurse care managers perform, along with Swedish’s nurse practitioners and patient care coordinators. But the key to their success is establishing a warm yet professional connection with each patient.
“How do we make contact with (patients) and motivate them?” is among the key questions Katie Miotke, one of Swedish’s first Care Coordination Scholar trainees, asks herself prior to a patient encounter. The 20-year-old Miotke is studying molecular and cellular biology at the University of Washington in Seattle. She expects to apply to medical school after she graduates in the spring of 2016.
Miotke said she was drawn into medicine and the Care Coordination Scholar program because of her mother’s work as a home health nurse, and because she has had family members confront serious health issues like Alzheimer’s disease.
“A lot of work is dealing with patients who for whatever reason don’t want to continue their medical care,” said Miotke, who has discovered that both diabetes and depression are prevalent in the populations she is advocating for, creating a formidable challenge right off the bat. “We have to change that, and figure out what the overall goals are for each patient.”
That is accomplished in part through a technique called motivational interviewing (MI). MI is a gentle yet persistent constructive dialogue with patients to ensure that they show up for needed medical services and pursue lifestyle changes to help improve their health in the long term. Such changes include improvements in fitness and nutrition, improved stress management, and ongoing management of any chronic conditions the patient might have, such as diabetes or congestive heart failure.
The intent of motivational interviewing is to instill in the patient a desire and drive to change, while still respecting their autonomy. Pros and cons of a patient’s current behavior and hoped-for behaviors are discussed in depth. Care coordinators are trained extensively in this process, which includes specific rules about etiquette, body language and eye contact – as well as the need to repeat the information to the patient in a non-confrontational manner until it is heard and processed.
“You need to make the patients realize this is what they want, these are steps for them to succeed, and that will be the biggest thing for their care (moving forward). You have to really get them to buy into the whole thing,” said Stephen Ong, another Care Coordination Scholar. The 23-year-old Ong recently graduated from the University of Washington with a degree in biochemistry, and is in the process of applying to medical schools. Ong was drawn to health care as a career after his father died of cancer when he was still a young child. To him, care coordinators “fill in the gaps regarding the health care they are receiving.”
Not everything operates smoothly – most patients eligible for the care coordination program have habits ingrained in them since childhood, and that can be difficult to change. “It can be frustrating,” Miotke said. There is specific training for Care Coordination Scholars regarding how to deal with patients who relapse to old behaviors.
Nevertheless, Miotke has found the experience rewarding.
“There have definitely been positive cases that come through,” she said. “You see patients through the course of weeks take pretty dramatic steps in changing their lives, and that is duly uplifting.”
Although Ong’s plans to become a physician are firm, he could still envision himself working as a Care Coordinator for several years to better prepare himself for the practice of medicine.
“There is definitely a need for the care coordinator. You could make it a viable career for sure,” he said.
Care Coordinators as a Permanent Fixture in Health Care Delivery
Given the enormous need for highly coordinated care within the U.S. health care system, care coordinators could play both a clinically and fiscally effective role in improving the delivery of medical services while reducing overall costs.
Since care coordinators would likely have an undergraduate degree but not possess a clinical license like a registered nurse or nurse practitioner, it is unlikely they would be paid at the same rate as those mid-level professionals ($60,000-$120,000 a year depending on experience and training, exclusive of benefits). However, care coordinators should be paid a living wage commensurate with their duties and experience.
Taking into account the premium of having an undergraduate degree and the minimum wage movement that is currently underway in the U.S., it would be reasonable to start a care coordinator at a wage of $17 to $18 an hour ($35,360-$37,400 per year), exclusive of benefits. A veteran care coordinator could command a salary just below that of an entry-level registered nurse ($52,000-$58,000).
Swedish’s Liga Mezaraups observed that given the crucial role care coordinators play as a link between patients and physicians, it is possible future hires could be trained social workers. Although social worker licensure is possible in some states without a graduate degree, that is becoming increasingly rare. Therefore a care coordinator with a master’s degree in social work could command a higher entry-level salary of around $40,000 per year, with peak earnings around $62,000-$65,000.
Compensation levels aside, care coordinators should always work under the guidance of a licensed clinical professional. Those would include a nurse, nurse practitioner, physician assistant or a physician, depending on the circumstances of the hiring organization. That would ensure an immediate resource if a patient has questions or concerns about their treatment that a care coordinator cannot answer.
Conclusions and Takeaways
Care coordinators will likely emerge as a significant resource for the coordinated care movement in the coming years, particularly as providers remain under pressure to avoid hospital readmissions and other collateral effects of loosely coordinated health care delivery. For most institutions, the position of care coordinators has yet to be determined; time will tell regarding their specific integration, duties, and compensation. In the meantime, organizations like Swedish Health Services and COPE Health Solutions are on the leading edge, developing forward-thinking care management programs for complex patients, and preparing the future care coordination workforce.
COPE Health Solutions thanks Ron Shinkman for his assistance in the development of this white paper.
For more information regarding Care Coordination, please contact info@copy.laraco.net
Footnotes:
1U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries. Commonwealth Fund, October 8, 2015. Accessed November 1, 2015. <http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective?title=High+U.S.+health+care+spending+due+to+greater+use+of+medical+technology%2C+health+care+prices&utm_source+=+toplinestwitter&utm_medium=social&utm_campaign=Toplines&omnicid=toplinestwitter>.
2Hong, Clemens S., Siegel, Allison L. and Ferris, Timothy G., “Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program?” Commonwealth Fund Issue Brief, August 2014, p. 8.
3Fortini, Robert J., “Core Value, Community Connections: Care Coordination In The Medical Home,” Patient-Centered Primary Collaborative, January 2011. p. 52.
4Press Release, October 27, 2015. Accessed October 31, 2015. <http://www.thescanfoundation.org/sites/default/files/field_research_medicare_medi-cal_polling_results_102715.pdf>.
5Kolata, Gina. “Death Rates Rising for Middle-Aged White Americans, Study Finds.” New York Times, November 2, 2015. Accessed November 6, 2015. <http://www.nytimes.com/2015/11/03/health/death-rates-rising-for-middle-aged-white-americans-study-finds.html>.