During my years working in hospital medicine, I had to develop a comprehensive checklist of items I worked through each time I discharged a patient. This included ensuring patients were counseled and educated, discharge follow-up appointments were made, prescriptions were sent to the right pharmacy and covered by insurance, contact information was populated in the after-visit-summary, and all members of the patient’s care team were updated on discharge plans.
I often likened myself to a symphony conductor, striving to synchronize all aspects needed to support a patient’s care journey upon leaving the hospital. However, this process required considerable time and effort, often at the expense of the many other tasks piling up throughout my shift. Outdated workflows — paired with cumbersome technological infrastructure that fomented frustration — made conducting consistent and dependable care coordination challenging.
To truly improve care delivery for patients and clinicians, systems will need to laser-focus on supporting and implementing well-conducted care coordination without causing more friction for care teams. And digital health technologies are perfectly positioned to help with that.
What makes care coordination successful?
On a basic level, care coordination involves organizing everything a patient needs during their care journey to support a positive outcome. This can include different providers partnering to determine medication schedules and treatment guidelines, establishing routine and predictable chronic care management screenings, and ensuring patients understand their at-home care guidance after discharge.
One of the cornerstones of successfully coordinating care is clear communication. Effective collaboration among care teams ensures that everyone involved in a patient's care is well-informed, aligned, and working toward shared goals. For patients, having clear, understandable information about their health conditions, treatment options, and self-care instructions empowers them to make informed decisions.
At a deeper level, effective communication must be supported by meticulous attention to timing. For some patients with more acute conditions, getting accurate advice for symptoms as they occur — instead of after encountering them for an extended duration — can be the difference between continuing to successfully manage illnesses or experiencing more severe outcomes.
But the current reality simply isn’t conducive to helping individuals with either communication or well-timed care support. In fact, a recent poll found adult patients in the U.S. spend eight hours or more coordinating healthcare every month, and that 65% of them find it “overwhelming.”
How can providers manifest patient-centered care when the people they aim to treat are continuously stressed by the barriers of existing systems? Healthcare needs to adopt new and validated technologies that can support individuals receiving care and the ones administering it to build a better blueprint for care coordination.
How can you support care coordination with digital health?
It’s one thing to commit your organization to improving care coordination and investing in new advancements to realize better outcomes. But it’s another to understand how technology can make a real impact. There are a number of functions to look out for when selecting a digital health tool to support your initiative.
1. Equip clinicians with accessible and real-time insights about patients
Care teams can’t strive to achieve optimal care coordination without the right patient information. Although EHRs have largely solved a piece of the puzzle by centralizing individuals’ medical data, this information is usually siloed and disjointed from the larger scope of care delivery.
Intelligent care enablement technologies have been developed to address this issue. Integrating seamlessly with care management systems, these tools give clinicians enhanced information, including longitudinal views of patient care journeys, messaging histories, and remote patient monitoring data.
Most notably, these digital health platforms extend the purview of care teams outside of the inpatient setting to better understand patient needs before, after, and between visits by automating proactive, conversational texts. This text-based approach can help uncover insights about the patient experience in real-time and flag issues early that might otherwise lead to an urgent care visit or return appointment — information that might have otherwise gone unreported if patients didn’t have the time to wait on hold or understand their concerns should be shared with their provider.
2. Reduce costly — and potentially harmful — duplicative care
Gaps in effective care coordination can inevitably lead to duplicative procedures and tests. And these redundant activities can cost health systems money and cause more stress for — or even harm — patients.
Indeed, obstacles to successfully coordinating care that lead to duplicate activities often take the form of clinical workflow inefficiencies. Innovative digital health platforms have built-in features for displaying testing information, visualizing the results in a simplified way, engaging patients with education resources and proactive communication, and collecting individual patient data beyond the purview of the hospital.
This has a two-fold effect. On the provider side, more and better-organized information is available at the clinician’s fingertips — meaning a more simplified way to check if an individual already received a test. On the patient side, they understand more about their care journeys after engaging directly with questions about tests, medications, and symptoms. So, if they’re instructed to visit a doctor for a specific procedure, they’re more likely to know if they’ve already undergone a similar treatment or test.
3. Streamline collaboration between providers
Some care journeys involve one doctor. But others might pull together multiple clinicians and medical professionals — including specialists, social workers, dietitians, and nurses. Successfully coordinating care in these scenarios entails careful provider collaboration to ensure the individual receives the right care at the right time.
Technology has classically filled the need for streamlined communication. But with email and messages becoming burdensome for providers, healthcare needs new solutions to streamline joint clinician activities.
That’s where intelligent care enablement platforms have started to solve the issue. Some innovative technologies enable providers to tag each other and have asynchronous discussions all within a patient profile. Clinicians need not worry about whether the right information will reach their counterpart — a patient’s profile, relevant care data, and escalated concerns are all made accessible when a physician is tagged.
4. Proactively help patients with care-related information
It seems like every hospital uses automated appointment reminders and portals. And for good reason: Reminding people about upcoming doctor visits and giving them access to their medical information can improve patient experience and streamline clinical workflows.
Though useful, neither of these basic automation technologies can comprehensively improve care coordination. An appointment reminder system doesn’t educate post-surgery patients about side effects they should expect while healing at home. Storing generic care instructions behind a password-protected login doesn’t help someone experiencing an unexpected fever in the middle of the night.
Health systems can no longer rely on outdated, reactive technologies and expect better care coordination results. They need proactive digital health tools that intelligently and automatically engage patients along their care journeys. Innovative intelligent care enablement platforms do just that by reaching out to patients with symptom surveys, reminding patients about medication refills or schedules, and even escalating concerning messages to the right provider.
As the demands of coordinating care become increasingly robust for clinicians and their patients, implementing the right strategies to bridge gaps in care delivery could be the difference between a well-conducted team working in-concert to provide quality care and a cacophony of clinicians scrambling to achieve effective collaboration. The most innovative digital health platforms can enable providers to put patients first while seamlessly orchestrating clinicians to perform at the top of their license.
Want to learn more about leveling up care coordination? Get our case study exploring how Penn Medicine accelerated access to fertility care.