Fundamentals of Care Coordination

Jim Molpus, for HealthLeaders Media , February 13, 2014
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This article appears in the January/February issue of HealthLeaders magazine.

No matter what size the health system or what degree of integration it may have, a plan for effective care coordination starts in the primary care practice. Danville, Pa.–based Geisinger Health System, even with its history of integration and care innovation, knew that to drive cost out of the care continuum it needed to understand how patients navigated through primary care and connected to other parts of the care continuum. And just as important, to determine who would help them navigate.

Geisinger already had a quality improvement system that combined evidence-based best practices, electronic health records, and outcomes to standardize care processes.

First pioneered by Geisinger in cardiovascular surgery, the model was fitted to care coordination and built on five fundamentals: patient-centered primary care, integrated population health management, an emphasis on "micro-delivery systems" including home health and skilled nursing, a focus on quality outcomes, and a physician reimbursement program built on value.

Shifting the "center" of primary care to the patient meant a different way of thinking about the role played by primary care physicians, says John B. Bulger, DO, chief quality officer for Geisinger Health System.

"The things we drive aren't really driven by physicians as the 'effector arms,' " Bulger says. "Physicians are very involved in helping define the protocols in working with their multidisciplinary teams to say what a patient needs. But the effector arms of these things aren't the physicians."

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