Care Transformation Center Blog

Don't take your eye off inpatient care coordination opportunities


Atul Gawande’s recent piece provided a behind the scenes look at The Cheesecake Factory and potential lessons for health systems.  In “Big Med,” Dr. Gawande discussed his mother’s knee replacement surgery and the 63 different people involved in her care—not  counting the bioengineers, pharmacists, and other support staff.

Based on his account, it would appear his mother’s surgery was a routine and fortunately successful operation. For many patients, however, coordination and communication among the inpatient care team results in gaps that can have a moderate to severe impact on safety, quality of care, and readmissions.

Many organizations investing in care coordination, but execution is key to success

With the increased focus on readmissions, many organizations have been investing in resources to support patient transitions and ambulatory care management, but effectively coordinating among caregivers during the inpatient stay remains a key opportunity.

Across various Advisory Board research programs, we’ve assessed key tactics to improve inpatient care coordination. While your hospital likely uses some of these tactics already, actual execution on the approaches is a key differentiator in determining success beyond implementation.

Three strategies to improve inpatient care coordination

Here’s a quick round-up of ideas for how to optimize approaches for boosting communication and coordination of the inpatient care team.

  • New care management staffing models: With so many roles involved in coordinating patient care, some responsibilities can fall through the cracks. To set clear accountability for ensuring patients are set up for a safe transition, some organizations have created specialized roles within case management to allow staff to focus on tasks that best fit their competencies. For example, creating referral specialists to work on discharge options vs. case managers who can dedicate their time solely to direct patient and care team interaction. One organization we interviewed has adopted a dyad model that pairs case managers and social workers to promote improved synergies and efficiencies in how they manage common patients.  
  • Revitalized interdisciplinary rounding: As simple as the concept is, interdisciplinary rounding continues to be a challenge, given the logistics involved with orchestrating everything required to make these huddles effective. Organizations that have been successful in instituting effective rounds have ensured clear staff accountability for attending and contributing to rounds, a consistent and concise format for the conversation, mechanisms for capturing information discussed, and have selectively broadened the scope of traditional caregivers involved in the process. For example, post-acute care liaisons help prepare the patient for discharge and ensure that the most appropriate post-acute site is selected.
  • Patient-friendly communication: Patients are particularly vulnerable to confusion and information overload during the inpatient stay, so it’s important to evaluate how providers are communicating key information to patients and their families. From revamping patient whiteboards to actually producing a daily care plan from the EMR translated into patient-friendly terms, providing patients with easy to understand information can improve the quality of care transitions and prevent unnecessary readmissions. Organizations are revising basic strategies- such as motivational interviewing – to ensure that the patient education moment is as valuable as possible. 

More resources on care coordination

For more information about resources for improving provider communication and coordination, check out the following studies:

To learn more about creating a strong platform for care management that spans the full continuum, save your seat at one of the Health Care Advisory Board's upcoming national meetings. Our latest research will provide insights and case studies on how to:

  • Establish a care management enterprise focused on capturing value from avoidable utilization and higher-quality care
  • Implement care management approaches that improve outcomes for high-cost, complex patients
  • Position health management leaders and functions to contribute to near-term success and the broader organizational transformation

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