Care coordination: What's needed to succeed with accountable care and home health?

Care coordination: What's needed to succeed with accountable care and home health?

Patients are increasingly opting to recover in the home instead of a hospital or rehab facility, which requires care coordination. Q. Why do you suggest that care coordination with post-acute providers will become more critical than before to support the rise of value-based care? There is no way to succeed in value-based care without effectively coordinating with the tens of thousands of nursing homes, home health agencies and other post-acute providers. Increasingly, we are seeing providers, all along the spectrum in their journey to value-based care, adopt technology that enables better coordination with post-acute care – from predictive analytics that enable matching of patients to the appropriate type of post-acute care to care management tools that provide ongoing real-time visibility into post-acute care settings. By leveraging care coordination technologies, home-based providers can help prevent unnecessary readmissions by, for example, identifying patients who are at rising risk and receiving real-time notifications whenever a patient presents at the ED. Many examples across the continuum showcase that the need for post-acute care coordination grows as more patients choose to recover at home. For example, historically, hospital and post-acute staff relied on multiple phone calls and faxes back and forth to coordinate the transition of patients out of the hospital and into post-acute care. Leveraging care coordination tools, hospitals can find the appropriate post-acute providers with a few clicks and electronically communicate with post-acute providers to streamline that patient transition. To tie it all together, in the shift to home- and value-based care, more coordination – rather than less – is needed.

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