4 Strategies for Improved Care Coordination


Doctors, hospitals, and community-based organizations are working together to coordinate care for vulnerable individuals in their communities. Successful care coordination acts as the bridge across these multiple systems and provides a whole-person view of these individuals.

While there is no single, widely accepted definition of care coordination, there are three key concepts:

  1. Comprehensive: All services an individual receives, including services delivered by systems other than the health systems, are to be coordinated
  2. Patient-centered: Care coordination is intended to provide whole-person care that focuses on addressing the needs of each individual rather than focusing on program enrollment numbers
  3. Access and follow-up: Care coordination is not only intended to connect individuals to services, but also to ensure services are delivered appropriately; i.e., that the information flows among care providers and back to the primary care provider

State Medicaid programs have long pursued greater coordination and integration of care in order to improve care outcomes, improve the quality of care, and reduce overall costs. In the last few years states have followed suit and are working to develop new delivery system strategies to improve care coordination and integration.

Strategy 1: Build Care Coordination Into Provider Standards for Medical Homes

Recently many states have worked to improve Medicaid delivery systems by implementing patient-centered medical homes. These medical homes deliver patient-centered, comprehensive, coordinated, and accessible care that is committed to quality and safety. The programs incorporated have enhanced, value-based payment plans that are aligned with national or state-developed qualification standards. They offer provider incentives for best practices in technology, improved quality, and reduced cost for primary care. One such state is Colorado.

Colorado’s Accountable Care Collaborative identified care coordination as a vital part of the medical home. Consequently, medical homes are required to take primary responsibility for care coordination for children enrolled in Medicaid and CHIP programs. They ensure there is a system in place for children and families to obtain information and referrals for community and non-medical services.

Strategy 2: Support Primary Care Providers with Care Coordination Entities

Some states have created community health teams to augment the care coordination delivered by primary care providers. Community health teams are usually comprised of multidisciplinary staff from nursing, behavioral health, pharmacy, and community-based providers. Teams work with patients in person and link individuals to important community resources. The state of Vermont is a leading the way in this area.

Vermont established regional community health teams as part of a Medicaid section 1115 demonstration waiver to integrate a system of healthcare for patients, improve overall health for Vermonters, and improve control over healthcare costs. In order for these teams to operate in Vermont, an insurance plan must agree to share in the cost. These commercial health teams provide community-based services and multi-disciplinary care that support areas of behavioral health, social work, and pharmacy. And the results are impressive. At the different pilot sites where the community health teams were installed, inpatient use and per person per month costs decreased by over 20% and emergency department use declined 31%.

Strategy 3: Build Care Coordination Requirements into Contracts with Managed Care Organizations

Managed care is a dominant delivery system in Medicaid, delivering comprehensive benefits to over 29 million Medicaid beneficiaries in 35 state Medicaid agencies. Federal managed care regulations require managed care entities to provide care coordination for each enrollee. In addition, states can set high performance expectations to strengthen care coordination and monitor that performance to ensure compliance. One example is the state of New Mexico.

New Mexico enrolls the majority of its Medicaid beneficiaries into a comprehensive managed care plan under a section 1115 demonstration waiver. New Mexico’s managed care contracts identify primary care responsibilities that align with the principles of the patient-centered medical home. In addition, managed care organizations contract with providers for additional services such as behavioral health, home and community-based waiver programs, special rehabilitation, and Medicaid School-based Services Programs.

Strategy 4: Implement a Multi-faceted Intervention to Improve Coordination Across Systems

Care coordination across multiple systems is far more complex than with a single system. In order to effectively coordinate care across multiple systems, states must take steps to improve communication and coordination between primary care providers and community-based providers. Some of these steps include:

  • Developing and promoting tools and resources
  • Building care coordination into electronic data transmittal systems
  • Offering technical assistance to providers
  • Developing measurement models to monitor care results

Oklahoma created a logic model that included all four steps for improving communication and coordination between primary care providers and child early intervention providers, including:

  • A referral form that provides early intervention providers information to assess the child’s needs and communicates the results of the referral back to the child’s primary care provider
  • The use of technology to provide reminders to ask patients about preventative services and current risk factors
  • A web portal that allows primary care providers to make referrals and receive feedback from community-based organizations
  • Technical assistance for practices on the use of the common referral form and both implementation and use of the web portal

Many states have already demonstrated improved outcomes through care coordination for individuals covered by Medicaid. In addition, some states are developing additional new and innovative strategies for improving care coordination. Eccovia Solutions is proud to work with these states to develop custom care coordination strategies that improve the lives of vulnerable individuals in their communities.

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