Care Coordination
Care coordination improves quality of care by communicating patient needs and preferences at the right time and to the right people. Individuals with multiple chronic conditions, limited functional status, and/or psychosocial challenges are vulnerable and more likely to experience adverse events and poor health outcomes. OneCare’s care coordination program helps teams identify individuals likely to benefit from a care management intervention to improve health outcomes and processes.
- Capture OneCare network performance through annual reporting on standard, national quality measures
- Create and implement focused, high impact payment incentive programs to drive change on established quality measures.
- Facilitate targeted, data-driven quality improvement initiatives in partnership with our network participants.
We are advancing our mission of supporting high-quality care and reducing health care spending through an unprecedented level of connection and coordination among our many different types of providers, across diverse care settings.
What is Care Coordination?
Care coordination is the organization of a patient’s care across multiple health care providers. Lack of coordination can lead to negative health outcomes for patients, increase use of emergency care, medication errors, poor transitions of care from hospital to home, and preventable healthcare expenses. These effects can have a larger negative impact on chronically ill patients or patients with multiple complex health conditions. In contrast, when care is coordinated, it can keep patients healthier longer, better manage chronic conditions, and experience care that is consistent with their health goals. Care needs to be coordinated in instances like:
- Follow up care after an emergency hospital visit.
- Care between a patient’s primary care provider and multiple specialists for a chronic health condition.
- A temporary stay in a skilled nursing facility.
- Health care providers coordinating with social services to help a patient with health-related social needs (HRSN), such as housing instability, transportation barriers or food insecurity.
As a statewide ACO, OneCare is made up of doctors, hospitals, and other health care professionals from across the state that work with our staff at OneCare to give patients high-quality, coordinated service and health care, improve health outcomes, and manage costs. Our data-driven annual quality measures, including our Population Health Model measures, are selected to focus coordinated care where it can have the highest impact on health outcomes.
1. Capturing Network Performance
OneCare tracks our network’s care coordination performance. This provides insight to identify areas of success and improvement. With this data, OneCare supports primary care practices in identifying those patients who may benefit from outreach and care coordination. Care coordination is a foundational element of OneCare’s Population Health Model.
Network organizations across the continuum of care all provide reporting to OneCare about their care coordination engagement with the member population. This reporting includes key elements of person-centered care, identification of a lead care coordinator, creation of a shared care plan, and the degree of cross-team communication achieved.
OneCare consolidates this data and provides actionable reports to our network including care team collaboration gaps, cross-organization workflow development needs and additional training needs on best practices in care coordination. This outreach may also look like ensuring patients receive annual wellness exams and promote the Vermont Department of Health offerings for wellness promotion in the community.
2. Incentivizing Performance
Care coordination is a foundational component of OneCare’s Population Health Model and a required activity in order to receive incentive program payments.
OneCare uses payment reform programs to incentivize provider participation in the care coordination program on a per member per month basis.
As organizations provide more care coordination services and meet population health model goals, they become eligible for payments.
3. Care Coordination Support
As an accountable care organization (ACO), OneCare provides resources, data, and support to primary care practices and community organizations to facilitate greater communication between primary care doctors, specialists, and/or care managers.
Trainings & Consultations:
OneCare also offers care coordination webinars throughout the year to convene our provider network and amplify best practices in care coordination that are working in our Vermont healthcare system to improve patient experience and health outcomes. OneCare network participants can learn more about upcoming trainings on our Provider Resource Center. These webinars—as well as one-on-one consultations with our care coordination specialists—ensure our network has the information, tools, and resources to be successful in meeting population health model goals and providing coordinated care.
Leveraging Waivers to Better Coordinate Care
As an accountable care organization (ACO) in the All-Payer Model, OneCare Vermont is able to access waivers that remove barriers to health care entities partnering to better coordinate care and increase access.
Some examples of the waivers provided to the OneCare Vermont network include ensuring patients can be transported from the emergency department to mental health facilities and improved funding for skilled nursing facilities so that patients can be discharged from the hospital to these facilities without delay. Waivers like these ensure patients get the right care for their specific needs while also opening much needed beds in hospitals around the state for other patients.
Find Care Coordination Tools and Guidelines on our Provider Resource Center:
Looking for our Care Coordination Toolkit? You will find it in this same spot on the Provider Resource Center.