Promoting Patient Recovery through Care Coordination

By Sean R. Muldoon, MD, MPH, FCCP, Chief Medical Officer, Kindred Hospitals

Research into contributors to recovery setbacks

1. Adverse events: an average of 10% of patients in a hospital will experience at least one adverse event, 50% of which are deemed avoidable³. 
2. Discharge delays: Studies have demonstrated an association between unnecessary discharge delays and negative outcomes such as mortality, infections, depression, and reduced patient independence⁴.
3. Avoidable readmissions: Approximately 27% of 30-day post-discharge hospital readmissions are considered avoidable⁵. Such readmissions cost hospitals an estimated $26 billion annually in care, and an additional $521 million in Medicare penalties in 2022.^6,7

Internal coordination can reduce patient setbacks

One strategy for combatting patient setbacks is to break down clinical silos within a care setting and increase coordination across various hospital departments.

Medically complex patients with multiple comorbidities often require a team of specialists who can address the different facets of their conditions. As more caregivers become involved in the patient’s treatment, there is an increased risk of miscommunication, which studies have found to be one of the primary causes of adverse and even sentinel events⁸.  

When physicians, respiratory therapists, dieticians, bedside nurses, and others formally collaborate as an interdisciplinary care team to develop a comprehensive treatment plan, they are able to more effectively treat their patients. This level of coordination has been shown to improve outcomes in ICUs^9,10. 

The benefit of interdisciplinary care team (ICT) collaboration is particularly clear when looking at patients requiring mechanical ventilation. One study found that when interdisciplinary teams of caregivers collaborated on long-term weaning plans, the result was a decrease in mortality and time on ventilator¹¹.

When physicians and caregivers approach each patient’s treatment as a team, they can improve outcomes and decrease patient setbacks.

External coordination can improve access to appropriate level of care

Care coordination between the current provider and external health entities is another initiative that can improve outcomes and decrease readmissions.

The AHRQ defines this care coordination as, “a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system”¹².

Initiatives to improve external coordination can be implemented at various stages and levels of care. For medically complex patients that may require treatment after their initial hospital discharge, this can occur between post-acute care (PAC) providers and payers.  When these entities collaborate to ensure patients receive the appropriate level of treatment for their clinical needs, they promote patient recovery and minimize discharge delays and readmissions.

Here are two examples of how care coordination programs can improve outcomes:

Overcoming barriers to discharge
In some cases, patients may clinically be ready to discharge to a lower level of care, but are unable to do so because they require special accommodation or because the subsequent care setting does not have capacity. When providers from different levels of care and payers work together, they can remove these barriers and help advance the patient along the care continuum.

Aligning medical necessity and the care setting
Medically complex patients may benefit from remaining in a more specialized care setting. If these patients do not receive the intensity of treatment they need from the outset, there is an increased likelihood of care disruptions and of readmission further along the recovery journey. Clear communication between all entities leads to a more comprehensive understanding of the patients’ clinical needs and ensures that patients have access to the care they require, thereby reducing readmissions in the long run.

How Kindred Hospitals’ Programs are Bringing Caregivers and Partners Together

ICT Bedside Rounding
Kindred Hospitals’ interdisciplinary care teams of physicians, ICU/CCU-level nurses, respiratory therapists, and rehabilitation specialists collaborate to develop patient-specific care plans, which can help maximize potential for healing and minimize length of stay.

As part of their advanced care delivery model, Kindred’s interdisciplinary care goes above and beyond standard practice by including the patient and family in the team. The physicians and clinicians gather at the patient’s bedside daily to discuss patient and family goals, milestones, and progress, and to provide education and answer questions. This not only improves patient and family experience but also increases patient understanding and adherence to treatment plans which can further reduce avoidable readmissions. 

Care Coordination Meetings
Kindred Hospitals also understand the importance of open communication with downstream providers and payers. As such, they have developed a program of care coordination meetings with payers that have many members at Kindred.

During this time, medical directors and utilization management nurses can ask Kindred case managers specific questions about each of their patients in Kindred’s care, allowing them to get a more complete picture of the patient’s needs. Kindred can also discuss barriers to discharge and payers can provide network access where necessary to facilitate patient advancement. 

In some cases, these discussions may lead to care conferences between Kindred, the payer, and the patient and family in which the parties can answer the family’s questions and guide the patient along the path to recovery. These care coordination efforts help ensure that patients receive the appropriate level of care, promoting recovery and mitigating risk of readmission.