To effectively move healthcare toward the goal of true value-based care, providers must be able to identify those patients who are at the highest risk for adverse clinical outcomes. Typically, the sickest 5% of patients consume almost 50% of the US healthcare dollars. Stratification of patients according to their risk is only the beginning of the journey to value-based outcomes. Effective management of the whole patient is rooted in highly effective care coordination.
Care coordination is at the center of this drive toward value, and it begins with comprehensive and timely communication across provider settings -- from the acute care setting to the post acute care setting and ultimately the patient’s home. The benefits are measurable and significant, both from a clinical and financial outcomes impact:
Benefits of Care Coordination
Improved quality of care and safety during care transitions
Reduction in duplication of services
Reduction in 30-day hospital readmissions
Reduction in emergency room visits
Reduction in overall spend per patient
There are many resources and tools available to providers to enhance their overall management of high risk patients with multiple chronic conditions. One model that the Corstrata team has had the opportunity to use and teach is the Sutter Integrated Care Management model as described:
“ICM is founded on the most efficacious practices, interventions and tools in the most recent literature. The goal of this model is to take the ‘best of the best’ and maximize patient support where the patient faces daily challenges – the home. The ICM model tenets include evidence-based, patient-centered practices in clinical management, self-management support, care transitions and care coordination. This evidence is derived from industry leaders such as Dr. Edward Wagner, Dr. William Miller, Dr. Stephen Rollnick and Dr. Eric Coleman, from extensive policy research, and from best practices from the fields of adult education and social psychology.”
Another valuable resource for tools related to care coordination is available through the AHRQ Website (Agency for Healthcare Research and Quality).
The AHRQ has assembled additional resources to help clinicians, clinical teams, and health care administrators measure care coordination and learn more about how to incorporate care coordination into routine primary care practice. The PCMH Resource Center contains papers, briefs, and other resources related to effective care coordination, including:
Care Coordination Accountability Measures for Primary Care Practice
The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care
Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms
Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions
Prospects for Care Coordination Measurement Using Electronic Data Sources
How can Corstrata assist with care coordination of patients with wounds?
Corstrata utilizes mobile technologies to create access to its board-certified wound care specialists to produce a return on investment for our customers. Corstrata assists providers in proper assessment of wounds during the initial assessment upon admission- whether the OASIS C2 in home health or the MDS in the skilled nursing facility. Additionally, Corstrata wound experts collaborate with providers to develop a wound program that includes evidence based, best practice wound treatments, staff education, pressure ulcer prevention program, and wound formulary redesign. Corstrata provides wound image and video consults that include accurate identification of the wound type and associated staging, precise wound measurement, and recommended treatment and wound dressing.
Contact us today for Expert Wound Care. Anywhere.
