Care Coordination (It is Often Anything but Coordinated)

In recent years, our health and behavioral healthcare systems have begun to embrace alternative provider payment models designed to enhance the value of the services they deliver.  That such an approach is considered an “alternative” (or even innovative by some standards) is truly remarkable.  Imagine purchasing a car, dishwasher or gym membership without any consideration of their value (i.e., the benefits they confer relative to the resources expended to acquire them).  In no other domain would we commit our capital to goods or services with such little regard for their utility or impact on our welfare.

So why has this peculiar exception prevailed within the healthcare industry for so long?  One could easily fill an ocean liner with actuaries, economists, policy specialists, industry insiders (and outsiders), all of whom would formulate cogent and well-informed opinions on the matter.  And their opinions would surely diverge.  Such “experts” might achieve a consensus on certain points but their conclusions would be tentative at most and subject to continuing debate.  There is no singular or definitive answer to this question and it is well beyond the scope of any article or treatise (much less a blog entry).

Industry stakeholders seemed to have converged on at least one point, however.  In order to enhance the value of any care delivered we must ensure it is properly “coordinated.”  This view places the service recipient (aka “patient,” “client,” “consumer,” “member,” etc.) at the nexus of an interconnected web of offerings whose purveyors carefully calibrate their interventions in accordance with the actions of their partners.  It presumes close and continuing communication among a multiplicity of service providers that should align and optimize the impact of their efforts and minimize inefficient or duplicative activities.  The recipient is the “hub” from whom many “spokes” emanate and connect to various health, social service and natural support providers.  The rim of this metaphorical wheel surrounds and connects these providers and ensures their activities are properly “coordinated.”  This approach seems eminently logical and a wealth of data supports it.  As with so many things, however, it is much easier “said” than “done.”

Care coordination may be variously defined according to the populations to which it is applied, payors involved and a host of other factors.  The healthcare field has witnessed a proliferation of care coordination activities in recent years, particularly for individuals with serious mental illness and related conditions.  For instance, in 2012 New York State adopted the “Health Home” model of care coordination in accordance with certain provisions of the Patient Protection and Affordable Care Act (ACA) that utterly transformed the manner in which many services were delivered to vulnerable populations.  This was a welcome innovation in many respects inasmuch as it was not limited to individuals with mental illness.  Health Home (HH) care management is available to those with HIV and other chronic medical (i.e., non-psychiatric) conditions.  In other respects, its arrival was anything but welcome.  It upended a longstanding model that afforded relatively robust and intensive care coordination services specifically for adults with serious mental illness.  This “Targeted Care Management” (TCM) model permitted care managers to maintain modest caseloads and to deliver a more comprehensive array of services than would otherwise be possible.  The HH model, by contrast, supports a diverse recipient population within financial and regulatory frameworks that yield larger caseloads and less intensive service offerings.  It is not uncommon for HH care managers to retain caseloads of 40, 50, 60 (or more) individuals with varying needs and life challenges.  The most diligent, dedicated and organized care managers must surely struggle to provide even a modicum of support to many of their clients under these circumstances.  To expect them to “coordinate” their services with a host of other individuals and entities with which their clients are affiliated is patently unrealistic. 

Nevertheless, this is one of many models touted as a “best practice” to which our State has committed considerable resources, and it is now inextricably linked with other services and systems on which our recipients depend.  An expanded array of Home and Community Based Services (HCBS) was recently made available to many individuals with serious behavioral health conditions, but their access to these services is largely dependent on their enrollment in HH care management and their participation in specialized assessment processes administered by their care managers.  In other words, care managers whose workloads were onerous prior to the implementation of HCBS must now facilitate their clients’ access to a new service line that necessitates the development of additional support plans, extensive communication with emerging payors and coordination with designated HCBS providers.  But there are still only 24 hours in an Earth Day.  It should therefore come as no surprise that statewide enrollment in HCBS is proceeding at a glacial pace and fraught with innumerable problems.

Examples of similarly disjointed and uncoordinated care abound among other populations, service settings and circumstances.  Yet the march toward Value Based Payment proceeds under the assumption our care coordination initiatives will promote its success.

Care coordination does indeed hold promise for society’s most vulnerable members, and it is essential to the success of any initiatives that aim to enhance the quality and reduce the cost of health and social services.  In order to fulfill its promise, however, it must bring sufficient resources to bear on the inordinately complex challenges many of its recipients face.  Their health and welfare and the integrity of our healthcare systems require nothing less.