“Please enter the exam room, loosen your shirt, and remove your shoes and socks. Someone will be in shortly to coordinate your care. . . . This might sting a little, but it will be quick.”
Obviously ludicrous.
And yet oftentimes in the shorthand way we talk about redesign of the health care system, we act as if care coordination was a thing that might come in a box, brought to us by a "care coordinator." Lots of arguments ensue about who should be a care coordinator--doctors, nurses, social workers, community health workers, AIs (yes, artificial intelligences)--but relatively little thought is given to what they should actually do.
Just yesterday, it hit me that our inability to think through the actions of the care coordinator is not just because people haven't looked in the coordinator "black box," but because there isn't anything in there. There just isn't anything that a person can do to "coordinate care." Coordinated care is a system property, just like safety. No one would ever say, "I am your safety provider." There ARE safety officers in health care, but their task is to find systemic risks and address them with systems changes: e.g., if similarly named or packaged drugs create dangerous confusions, change the packaging. Or if the interconnectability of intravenous lines and naso-gastric feeding tubes creates a risk of putting "food" into a vein, change the gauge of the tubes or the locking systems.
In the models the Foundation has supported that seem to have "care coordinators," the coordinator is either explicitly a band-aid for a broken system or just the tip of the iceberg of a more fundamental system redesign. (Of course, some are in between.) In the IMPACT model, the depression clinical specialist is a new role who has some of the features of a care coordinator (e.g., calling patients, facilitating the flow of information between other providers), but he or she is part of a more fundamental redesign where a registry is used to guide care over time, a clinical team takes collective responsibility for outcomes, and the clinical specialist also delivers an otherwise unavailable brief psychotherapy.
At the other end of the spectrum, Eric Coleman's model is explicit in recognizing how the broken system can adversely influence older adults (and family caregivers) ability to self-manage chronic conditions during transitions across care settings. He says," The system is broken and fragmented. The role of the Transitions Coach is to empower the only stakeholder who is both interested and available across all settings of care --the patient/family." I don't think that anyone should feel proud that a patient, by default, has to carry a list of medications from site to site of care and have the chutzpah to make clinicians read it and reconcile any new medications with it--one of the "Four Pillars" of Eric's model. I think we are already paying doctors and facilities for this service and just not getting it. In a real system, medication lists would be shared electronically across settings and time, automatically monitored for potential conflicts (which providers would not just turn off or ignore), and there would be clarity across patients and prescribers for the responsibility and accountability of outcomes.
I suppose one's position on this issue will be strongly influenced by what part of the fragmented system of care one is most concerned about. If you look long and hard at the disconnection of people from benefits (e.g., Medicaid, meals on wheels), community based supports (e.g., exercise classes at the Y, caregiver support training at the library), and psychological assistance (e.g., a peer to peer program, or support group at church), you probably conclude that what is needed to coordinate care is a social worker who can advise and coach a person and family into those kinds of programs while offering the direct support of a caring advisor.
If you worry about people being confused about which medicines to take when, not knowing what not to eat to keep from returning to the hospital, and not understanding the prognosis of a disease well enough to plan in advance for the end of life, you probably think that the missing ingredient is a nurse.
And if you are very wishful about a past that probably never existed, you think that there should be just one person who could take care of all of your needs, really know everything about you, and be a respected expert - you would want your one per lifetime, full-service "family doctor" who follows you in the hospital, attends in the nursing home, and provides a wide range of office services at convenient hours and reasonable prices. Since we are imagining, why not add in that this mythical PCP should have been present at the patient's birth and hung around to help give death dignity and meaning despite the unlikely longevity required for that level of comprehensive care. If you find one of these, let me know.
The reality is, we don’t need a super-doctor for care coordination. Care coordination is a system property that requires careful redesign of plans and procedures, new hardware and new software, and yes, new people in new positions, but none of these features taken alone defines care coordination.