Transforming Health Care from Volume to Value: Leveraging Care Coordination Across the Continuum

Abstract

The care continuum represents a longitudinal, patient-centered view of clinical care within an integrated health system, providing patients consistency in discrete healthcare encounters, while accounting for their medical needs and personal context. Failure of effective care coordination occurs when patient transitions between care settings are disjointed or fragmented. These failures account for a substantial portion of the waste in the United States healthcare system. In this article, we propose target areas for care coordination interventions and describe potential cost savings. We focus on maximizing the appropriate utilization of the Emergency Department by promoting urgent cares, primary care providers, community healthcare workers, targeted interventions for high utilizers, observation units, and hospital-at-home programs. We describe strategies for working across the care continuum to build multimodal post-discharge care programs and partnerships, such as nurse discharge navigators, early clinician follow-up, specialty post-acute care clinic visits, community partnerships, and collaborations with post-acute care settings. To help drive improvement across other hospital systems, we propose a tangible blueprint for interventions to address failures of care coordination across the care continuum.