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How Value-Based Care Can Achieve Seamless Coordination and Communication


In this first of a two-part article series, Curtis Gattis, CEO and co-founder of LeadingReach, discusses how healthcare organizations participating in risk-based contracting or value-based financial and care delivery models are currently facing major challenges with integrating, managing and tracking care coordination and communication capabilities within provider networks.

Healthcare organizations participating in risk-based contracting or value-based financial and care delivery models are currently facing major challenges with integrating, managing and tracking care coordination and communication capabilities within provider networks. Poor coordination and communication not only cost the healthcare industry billions of dollars each year but also negatively impacts patient outcomes.

In the U.S., about 80% of all serious medical errors involve miscommunication during care transitions to different settings, which results in costly readmissions, missed appointments, medication errors and other preventable harm. It’s fair to say communication in healthcare is broken.

Curtis Gattis

Curtis Gattis

For value-based organizations to manage costs and deliver better care to patients, it’s essential to identify care coordination and communication challenges and use communication and data-driven insights to overcome them. The goal is to improve processes, and the best way to do that is by connecting networks and bringing together disparate HIT infrastructure.

Why care coordination and connecting networks matter

As value-based care models continue to take center stage in the healthcare landscape, it is critical to manage referrals and ensuring that patients get the care they need in a timely manner at the “appropriate setting of care according to their health plan.”

Many organizations, regardless of their tenure or how far along they are in their value-based journeys, face key challenges that stunt their ability to consistently deliver the level of care they intend to provide. For accountable care organizations (ACOs) and other value-based organizations that aren’t satisfied or lack key capabilities in this area, addressing the challenges requires a reassessment of workflow and care delivery processes. In many cases, the success or failure of value-based care is largely driven by care coordination processes, which impact your ability to communicate and manage patient transitions and referrals.

Establishing an integrated network requires implementing the right tools upfront, and achieving this level of coordination has historically been a challenge given that most providers use different EHR systems. Full visibility across your network requires a stackable platform that sits on top of legacy EHR and existing HIT infrastructure to bridge data gaps and communication silos. Once tools are implemented to enable care teams to ubiquitously communicate internally and externally, it’s easier to identify where workflow bottlenecks are occurring. Identifying overarching operational and clinical care coordination and referral management goals are key to improving value-based processes.

Top 4 goals for improving care coordination

It is impossible to get a complete picture of your provider ecosystem when disparate EHRs cause data silos. However, when your network is connected using a digital platform, your organization will be equipped with insights needed to identify problem areas and opportunities for improvement. Here are four ways to solve care coordination problems:

  1. Digitize referral communication
    Most manual, outdated communication processes have been digitized in every industry in today’s modern world except healthcare. More than 75% of healthcare’s referral-based communication are still sent via fax, but only 54% of faxed referrals result in scheduled appointments for patients and 25-50% of referring providers don’t know if their patients actually saw the specialist. Not only do value-based organizations struggle with closing the loop, but they are unable to hold providers accountable for the patients they should be seeing. By implementing a digital technology platform across your network, care becomes more accountable, traceable and coordinated.
  2. Redirect referrals to in-network providers
    Tracking and closing the referral loop is important, but tracking referrals becomes more valuable when you have full visibility into where specifically those referrals are going. Keeping patients in-network helps ensure patients get the most appropriate care from the most appropriate setting, while reducing the chance of network leakage. It’s great for the PCP to know their patient’s appointment was scheduled, but your organization also needs to see that the appointment was scheduled with an in-network specialist. This capability becomes accessible when you have a tightly integrated network of providers.
  3. Add specialists notes to the EHR
    This goal speaks to the importance and need for digital communication to fully replace inefficient manual processes. With a staggering 63% of referring physicians dissatisfied with the current referral process due to lack of timely information and inadequate referral letter content, there is a massive opportunity to enable more informed, collaborative care for patients. Provider-to-platform direct messaging enables seamless and real-time communication.
  4. Check the status of patients
    This is the foundation of successful value-based care. If you can’t identify where your patient is, where they are going and the outcome of suggested care visits, you can’t ensure they’ve received the care they need. The primary value of a connected network is transparency and accountability for both sides of the referral with nothing slipping through the cracks. Updating and changing statuses on outgoing referrals is the simplest and best thing your referral network can do to ensure an accountable transition of care.

    Leveraging a referral management platform with a tightly integrated network of specialists allows you to move from a “rear-view mirror” management style based on claims data to a “windshield view” style. Making proactive, data-driven decisions is crucial to establishing your connected digital network and ensuring patients are receiving the care they need in a timely manner.

Curtis Gattis is the CEO and co-founder of LeadingReach, a healthcare platform and care coordination company in Austin, Texas.

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