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Thoughts from the 10th Annual Care Coordination & Transitions Congress

Earlier this year, the 10th annual Care Coordination & Transitions Congress convened in Atlanta, GA. I, along with thousands of other healthcare professionals, attended to learn modern approaches for improving patient outcomes and financial sustainability through strategic care management. This summit assembles thought leaders from hospitals, health systems, home care, health plans, and managed care organizations to discuss best practices for improving care coordination, reducing readmissions, preventing avoidable health care utilization, and collaborating across the care continuum. This year, two distinct themes emerged: the ongoing importance and struggles of social determinants of health and the criticality of properly developing care management teams. 

The importance of social determinants of health have been stressed over the past years, but now they can no longer be denied in the mission of achieving better health. Social vulnerabilities such as low income, poor education, unsafe physical environment and unemployment can result in limited accessibility to care and higher rates of disease. With health systems often times being best positioned to address both clinical and social needs, they should be looked to as the conveners of resources across the care continuum. And with value-based care arrangements requiring providers to remain more concerned with quality of care, physicians are becoming more aware and accountable for what goes on outside their walls, so getting involved is a necessity. Health systems that don’t embrace this critical piece to patient health will risk higher rates of readmission, worsening patient outcomes, and higher patient attrition compared to their peers. The promising thing is, there is a swath of screening assessments and tools to help clinicians understand all factors impacting patient health, including predictive analytics to proactively manage risk elements. But it can’t stop there. Industry standardization (and adoption) is still lacking. Hospitals, providers, payers, government entities, and community organizations will begin to synergize to make worthwhile strides in this arena. Systemic efforts of capturing, curating, and leveraging social determinants of health in understanding patient risk will remain a priority in the upcoming years.

With new data and strategies focusing on social aspects of patients’ health, care team members will need to be more empowered to act on the information these data reveal and connect a patient to the help they need. With hospitals becoming more aware of social needs and the impact to overall health, they must be willing and able to partner with community-based organizations and work in tandem to ensure patients are getting needs met.  In 2019 and beyond, the development of more elevated care teams will be essential to support this shift in patient care. The care teams of tomorrow will require more education, standardization, and data than ever before. These teams will continue to take on more responsibility and remain accountable for improving quality and patient retention while reducing costs. Expansion in this area has been fast and inexperienced care teams are becoming a norm and will be even more costly. It is important for executives and hospital leaders to invest in these teams now: staff selection should be scrutinized as care team members should be outside-of-the-box thinkers, cross-discipline trained, and fearless in their advocacy for their patients. Strategic, continuous education programs for these teams are a must. In addition, leaders of these care teams must be equipped with technology for managing workloads and tracking metrics. Helping keep a constant pulse on how care teams are performing creates agility and confidence in performance and also alerts where other development opportunities may exist. 

An evolution of care management and coordination is taking place, as are the data that will dictate success. A long overdue shift in care delivery is occurring. Healthcare executives must change their historical ways and embrace new perspectives and practices. We will get back to what is right with healthcare and focus on the overall improvement of our population’s health. 

Need some help navigating these upcoming shifts in care management? We at NtelliSights have the NSide advantage and we are here to help.