ABCs of Care Coordination Part 1

With so many terms floating around in care coordination it can be difficult to keep everything straight, especially when terms sound similar. To help, we’ve done a round-up of common terms and definitions.

Community care coordination seeks to improve patient health by addressing the social determinants of health directly. This involves partnerships and even integrated delivery models involving primary care, behavioral health, and community-based providers to jointly address all aspects of a patient’s condition. Because of the high level of coordination required, numerous titles have been used to describe the coordination manager: Case Manager, Care Manager, and Care Coordinator.

A case manager assesses eligibility for specific programs (i.e. food stamps), enrolls clients in programs, and monitors client progress. The goal is to enroll clients in applicable programs as a means to achieving desired outcomes. In general, case managers work with human service programs such as housing, workforce services, child and family services, food assistance, etc.

A care manager works more directly with patients to manage their health conditions and reduce the need for additional medical services. Care managers are traditionally found in hospitals and other clinical settings and often work with patients who have chronic illnesses.

Care coordination is where case management and care management come together. A care coordinator (or patient navigator) focuses on treating both the medical needs and the social factors (the social determinants of health) that affect the health of an individual. A care coordinator has visibility into all aspects of an individual’s care and serves as the point of contact for patients as they work with providers across the spectrum of care.

Along with similar sounding job titles, another confusing aspect of care coordination is the myriad of care models, each with its own unique characteristics. Some of the more common ones are:

  • Medicaid Waivers — States can apply for Medicaid waivers to fund programs that target a specific population for health care services. For example, 1915 waivers fund home and community-based care services for targeted populations, to avoid care delivered in higher-cost settings. A state may run multiple waiver programs simultaneously.
  • ACO — Accountable Care Organization. ACOs are groups of doctors, hospitals, other providers and medical facilities who voluntarily unite together to deliver coordinated care to Medicare patients with the goal of lowering overall cost while improving patient outcomes. Providers are financially rewarded with a portion of the program savings.
  • Next Generation ACO — The Next Gen ACO is an opportunity for an ACO with a proven track record to take on additional risk in patient care for potential additional reward. The NextGen ACO model seeks to deliver better patient outcomes at even greater cost savings than under the traditional ACO model.
  • MCO — Managed Care Organization. An MCO is similar to an ACO in purpose (lowering cost of care) but differs in the population served. MCOs typically serve patients covered by commercial payers or self-pay patients.
  • Integrated care — An integrated care model combines medical health and behavioral health care. Patients may receive services typical of medical care in a behavioral health setting and vice versa. The goal is to increase screening and delivery of mental health services by integrating these services into the care patients already receive.

Each model of care shares common goals, such as delivering better care at a lower cost, but each model uses slightly different methods to achieve the goals. There is great flexibility even within categories: Medicaid waiver programs, for example, can take a variety of different formats as long as they meet the established program criteria.

Now that we’ve got that straight, next we’ll look at common terms used in describing the technology infrastructure that enables service providers to make these improvements in care delivery.

Resources

https://innovations.ahrq.gov/topic-collections/community-care-coordination-glance

https://innovations.ahrq.gov/sites/default/files/Guides/CommunityHubManual.pdf

https://www.chcs.org/media/ACO-Fact-Sheet-06-13-17.pdf

https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/

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