Healthwise Care Coordination Team
Editor’s Note: In these posts, we’ll explore six steps for developing a care coordination program that increases revenue, cuts costs, and enhances the quality of patient care. In this post, we’ll look at how to build personal and consistent experiences for every patient by using standard care plans.
We’ve heard it before. Or we’ve said it to ourselves. “If I just had a game plan, I could stay on track and get to my goal.” Maybe it’s a game plan, maybe it’s a road map—whatever the visual is, it’s a familiar concept to many of us.
This is how a care plan functions for an entire health care team, including the patient. Simply put, it’s a guide to get to a goal.
Standardizing plans for common patient situations promotes a higher quality of care. For instance, when my mother-in-law, Lucy, was preparing for a total knee replacement, she had a very clear idea of what to expect. Her care team helped her with ideas about how to prepare for every step in the process, including eventual rehabilitation. The care team had a game plan. They worked with Lucy to get stronger before surgery so she’d have fewer complications and an easier time getting back to her normal activities.
Standardizing care plans also provides an opportunity for your care coordination team to get on the same page. And after you know what your organization’s main goal is and what clinicians and care coordinators are doing to reach that goal, you’ll be ready to map out the steps to building standardized care plans.
One: Train your care coordinators
As she was preparing for her knee replacement surgery, Lucy was in touch with her care coordinator more frequently than with her doctor. Her care coordination team was trained to provide a caring and helpful experience to patients.
What is your program’s strategy for achieving better patient outcomes? What is the care coordination team’s role reaching their goals while keeping Lucy’s goals in the forefront? In order to succeed on the job, teams need training, ongoing support, and awareness of the organizational goals. When the care coordinators have these things, they’re in the best position to help patients succeed, too.
Two: Define patient care plans to standardize care and education
What do you see when you picture your patient education materials? Does each clinician or care coordinator have their own stash? Or are they delivering consistent information from an organization-approved resource? Defining what happens at each step of a care plan streamlines the process and raises efficiency. Standardizing educational materials helps everyone—patients, families, and clinicians—by ensuring that your patients get the right information every time, at every step in their health journeys.
For Lucy, having an overview of the joint replacement process was key to her success. She could discuss any concerns with her care coordinator and then mentally and physically prepare for the next steps. Her care team learned that Lucy could control her fears or concerns by learning as much as she could about a total knee replacement surgery. The team worked with her on this by teaching from the patient education materials.
Three: Develop metrics for tracking compliance
How do you determine if standardizing care plans is working in your program? By capturing and measuring clinical metrics, you can identify process gaps and other possible inefficiencies. In Lucy’s case, for example, you can measure whether she follows the strengthening program suggested to her, and if she continues seeing the physical therapist while she’s preparing for surgery and while she’s rehabilitating.
These metrics—facts about the patients—are ones that you can affect and ones to which you can assign a value. Tracking these values can tell you whether the quality improvements you make lead to the desired outcomes.
Four: Provide education prior to an admission for preplanned surgical procedures
Like Lucy, many patients do better when they feel prepared for a procedure. Having a clearer idea of what to expect before, during, and after a procedure can reduce complications and readmissions. No one wants to have setbacks. Standardized care plans—along with patient education and preparation—can help avoid that.
Five: Identify the areas in the patient experience when and where patient education can make a difference
There are certain times in care where patient education can make a big impact. Let’s think about Lucy’s situation again. She relied on patient education in all phases of her knee-replacement decision. At first, she considered all of her treatment options and made decisions based on what she learned from her providers and her care coordination team. Then she weighed the options for surgeons, surgery centers, and therapists. Lucy’s care team also reminded her to consider what kind of preparations she needed to make in her lifestyle and around her house.
Six: Personalize care plans for better outcomes
One thing that the care coordination team did for Lucy was to personalize the standardized care plan for her. Lucy is the type of patient who benefits from a specific goal. She wanted to be able to continue working in her garden, and she worried she wouldn’t be able to kneel. Her care plan made that a rehab goal. That way, Lucy’s physical therapist could concentrate on exercises to move her in that direction. Lucy stayed engaged throughout the process because she could see how she was going to reach the goals in her care plan—goals that she wanted to achieve.
When you personalize a standardized care plan, you balance those two factors—the standard and the personal—while you help patients achieve better outcomes. Lucy’s knee replacement surgery was successful, and she credits much of that success with being well-informed and prepared. Her knee is strong, and she’s looking forward to planting this year’s garden.
Read our eBook, The State of Care Coordination: 6 Illuminating Strategies You Should Know, for more information on best practices in care coordination to facilitate change.