Four care coordination network strategies to achieve the Triple Aim objectives
Healthcare systems are under an increasing amount of pressure. . At the same time the shortage of professional healthcare providers is increasing. As a result, the government is asking people with complex long-term healthcare demands to stay at home as long as they can. The government also encourages people to offer care and support to others. Healthcare providers are seeing their work shift from intramural to extramural. They are also dealing with more and more volunteers and informal caregivers. The question is: what is the best way to make this work in practice? Better care coordination is seen as the solution. But what exactly is care coordination, how do you organize it and what can it help you achieve?
Social networks improve health
International research has pointed out that 36% of the condition of your health is due to individual behavior and 24% can be explained by social circumstances (image 2). So if you want to improve people’s health, you should work on these factors. And it does actually work. International research has also shown that social networks have a demonstrable effect on for example smoking, diet, exercise, depression, compliance and obesity. A good example is a recent study amongst patients with a chronic heart condition or diabetes. The results show that influencing healthy behavior mostly happens through a patient’s social network. Leading to less hospitalization and lower costs. A coordinated network approach offers promising opportunities to really improve healthcare.
Image 1. What influences health?
What is a coordination care network?
The next question is: how do you organize healthcare according to network principles? Let’s start by giving a definition of a coordinated care network, because there is a lot of confusion about this. Not least due to the enormous list of synonyms that are being used: integrated care, managed care, continuity of care, case/care management, transmural care, patient-centered care, shared care, you name it. All terms that boil down to the same thing and to which the following definition applies: Network care is a coordinated way of cooperating between a group of healthcare providers to improve the healthcare outcomes of (part of) a population. The healthcare providers are willing to jointly carry the risk for the quality and cost of care. To make it more concrete: a chronic patient with comorbidity will easily have to deal with ten healthcare providers: their GP, medical specialists, a physiotherapist, their district nurse, domestic help, their pharmacists, Social Support Act workers, informal carers, volunteers etc. All these people have their own role and responsibility in the (health)care process. If they work together in a coordinated way and carry the responsibility together, then it’s called a coordinated (health)care network. The goal of a coordinated (health)care network is to improve the accessibility, quality and efficiency of care and to increase patient satisfaction. It’s not a goal in and of itself, but a means of realizing value-based care – also called value-based healthcare or Triple Aim.
Why do we need coordinated care networks?
Very simple: to adapt to the changing healthcare demands. A normal phenomenon. Along the course of history, the healthcare system has constantly adapted to changing circumstances. The primary goal at the end of the 19thcentury was to fight infectious diseases, now the challenge is in fighting multiple chronic diseases. The only way we can do that is by operating in coordinated care networks.
Four strategies to organize a coordinated care network!
Coordinated care networks are seen as the answer to the increasing demand for care and the rising costs of care. This model distinguishes between four domains that we need to act on. At the macro level it’s about rules and regulations, at the meso level it’s about cooperation between organizations and professionals, and at the micro level it’s about self-management support for patients. Based on the Rainbow Model (Image1), there are four types of care coordination networks you can distinguish between:
1. System networks
2. Organizational networks
3. Professional networks
4. Patient networks
Image 2: The Rainbow Model
The patient is the most important pillar within a coordinated care network. The self-reliance of people is high on the political agenda at the moment. People are being encouraged to manage their own health better, potentially with the help of informal carers and volunteers. But this only works if patients have insight into the quality and cost of the care offering and if they are owners of their own health data. Unfortunately, that isn’t ideal in practice. The input of the patient in their own care process can be optimized by eHealth applications and self-help equipment and educating people on how to use them. In addition, it is important to have regular clear communication with the healthcare providers of the care network and with their peers. This will only be possible if there is a legal framework for access to your own health data, transparency about treatment outcomes and accessibility to information systems.
Interprofessional cooperation between healthcare providers is at the core of a coordinated care network. This is characterized by joint quality frameworks, guidelines and protocols and multidisciplinary consultation within primary healthcare (healthcare centers, GP centers and healthcare groups) and medical specialist within hospitals. Vertical forms of cooperation between generalist and specialist are, unfortunately, very rare, even though they are essential for successful network care. To achieve this, other legal and financial frameworks are necessary. It is only then that the profession of healthcare provider can develop towards ‘organized professionalism’. This means professionals enter into partnerships in the area of prevention, care and wellbeing within the supporting (virtual) coordinated care networks.
Through new types of value-based contracts (like bundled payments and shared savings) they are appointed more responsibility for clinical and economic healthcare outcomes.Payment will become an incentive to offer the best care at the lowest possible cost. This leads to clinical and financial risks that are hard to control at an individual provider level. That is why new interprofessional standards, curriculums, studies and associations will come in, which is already common in law and accountancy for example.
Healthcare professionals work for organizations and those organizations have to enter into all types of alliances to make coordinated care networks a success. Research has shown that a regional approach is most effective for this. In order to obtain a fruitful cooperation between organizations, data exchange and integral forms of finance form undebatable requirements. If we take the example of disease management and managed care in The Netherlands: health insurers can use bundled payments with GPs and medical specialists to encourage cooperation between primary and secondary care. They also ensure good coordination of care and joint responsibility of Triple Aim (medical, social and economic) outcomes. In that respect we can learn a lot from initiatives like Accountable Care Organizations and Patients Centered Medical Homes.
Unfortunately, in high income countries like the Netherlands, US, and Germany, healthcare is extremely fragmented both in terms of financing and policy. The differences in scale, organization and orientation between healthcare insurers, national governments and local municipalities cause coordinated care networks not being implemented in practice. Coordinated care networks demand an integrated and evidence-based policy which goes beyond the traditional organization and financing silos. It is important that we develop sustainable long-term strategies for coordinated care networks across for the health and social care sectors. This also demands integrated rules and regulations and accompanying forms of financing. Without these prerequisites, putting coordinated care networks into practice will become a mission impossible.
The show must go on. But who will take the lead?
It is becoming more and more clear that coordinated care networks are the answer to the increasing demand for care and rising healthcare costs and that it’s time to take action. But it’s not going very fast. Why is that? It’s not due to the individual motivation of patients, professionals and volunteers. They are motivated but running into barriers. Looking at the Netherlands, the biggest showstoppers for coordinated care networks are:
1. The lack of integrated policy between healthcare and social care;
2. Fragmented financing between primary, secondary and tertiary care;
3. A lack of data exchange between primary, secondary and tertiary care.
These are all factors that – interestingly – are at the level of system and organizational networks. So that’s the key. The million-dollar question is: who takes the lead? From which angle do we take it? The Ministry of Health, Welfare and Sports with a four-year policy agenda? The Public Health Inspection? The Dutch Healthcare Authority? Or the health insurers? It’s sad to observe that the policy-based ’thinking in boxes’ in the Netherlands doesn’t really help to put coordinated care networks into practice. Integrated compliance, control and financing have proved to be difficult in our segregated healthcare system. When everyone knows that the whole is more than the sum of its parts…
Many international best practices actually show that a coordinated care approach leads to better Triple Aim outcomes. There is a desperate need for people who think outside the box to make integrated policy and financing a reality. An integrated policy agenda and administrative decisiveness could be the foundation for creating regional coordinated healthcare networks at the patient, healthcare professionals and organizational levels. Networks that offer high-end, people-centered care, that use the latest technology and that give the desired Triple Aim outcomes fast because of their engagement with the patient: higher patient satisfaction, better healthcare outcomes and lower costs. It really is possible, if we’re willing to step out of our own shadows!
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