Editor’s note: The Caregiving Chronicles blog has partnered with Century Health Systems to bring additional expert information and advice to the MetroWest caregivers we strive to serve at CaregivingMetroWest.org.

Century Health Systems, the parent corporation of Distinguished Care Options and the Natick Visiting Nurse Association, has allowed Caregiving Chronicles to get some valuable insight from its staff for our ongoing series of Q&A sessions with caregiving experts. In this entry, we cover what caregivers should know about the issues involved with the coordination of care. Providing insight is Judith Boyko, MBA, MS, RN, who has served as the CEO of Century Health Systems since it was established in 2001.

Boyko holds a Bachelor of Science degree in Nursing from the University of Pittsburgh, a Master of Science in Public Health from the University of Massachusetts, Amherst and a Master of Business Administration from Clark University. She has been recognized by the Home & Health Care Association of Massachusetts as Manager of the Year in 1997 and received the Deborah Blumer Community Health Leader Award from the MetroWest Community Health Care Foundation in 2007. She can be reached at infonvna@natickvna.org.

Boyko: Being in the hospital for illness or injury is stressful enough – for patients and their families alike.

But there’s added stress when a loved one comes home after a hospital – along with myriad questions: Will she be OK? How is she going to heal effectively? Did I line up the right care?  How do I access that care?

Coordinating care for a loved one can be very complicated, especially when the patient needs special equipment, complex medications, professional caregivers, wound dressing changes, therapy and more.

So, where does one begin when planning a loved one’s return home?

Let’s begin with some basics. First, what does coordinating care mean? According to the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality, “Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.”

Caregiving MetroWest: Who needs to be included in the coordination of care?
Boyko: The team is multi-faceted and multi-disciplinary. A typical team involves the patient; the patient’s family caregiver or other caregiver(s); a primary care physician; and any specialists involved in treating the patient, including doctors; nurses; therapists; social workers; dieticians; a pharmacist; and others.

CGMW: What are the benefits of care coordination or the risks of failing to coordinate care?
Boyko: The care coordination team works to establish the best plan of care for the patient while taking into account the patient’s clinical and lifestyle goals as well as her financial status and health insurance coverage .

The benefits to the patient (and caregivers) include increased patient satisfaction; fewer hospitalizations and ER visits; better care outcomes; improved quality of care from those delivering it; and lower costs to the patient and the health system.

Another benefit is education. Family caregivers are often the people who are taught how to care for a loved one when a medical professional is not present. For instance, upon a patient’s return home, the caregiver may be taught how to administer a medication or give an injection; ensure the patient’s safety through safe ambulation techniques; or change wound dressings, to name a few. Family caregivers may also take on the role of ensuring that all medications are available when the patient returns home.

Poorly coordinated care – or care that’s not coordinated at all – leads to errors, higher hospital readmission rates and therefore higher costs, difficult transitions among and communication between providers, and duplication of services.

Effective care coordination may also involve home safety evaluations. If the patient needs a stair chair, hospital bed, walker, or other adaptive equipment, for example, a physical therapist will be able to identify the individual needs of that patient. Without this safety evaluation, the necessary equipment may not be installed in time – or at all. And, many times, the caregiver doesn’t know how to arrange for it or is too overwhelmed.

CGMW: What role does the caregiver play in coordinating the care of their loved one?
Boyko: United Hospital Fund, in its “A Family Caregiver’s Guide to Care Coordination,” says it best: “A professional care coordinator’s job is to coordinate services. A family caregiver’s job is to coordinate life.”

We all know how taxing it can be to serve as a family caregiver. Most aren’t compensated for their time, and many put their own lives and needs on the back burner while making the care of a loved one a priority.

But the family caregiver plays an integral role in the coordination of care. And just as every patient has a different story, so does every family caregiver, who may have to fulfill the following responsibilities:
•    Ensuring the patient follows the prescribed plan of care
•    Providing transportation to and from doctors’ visits
•    Serving as a conduit between the professionals and the patient; the professionals can teach the caregiver how to use a telemonitor, for example, and the family member can help the patient in the home when the care team is not there
•    Accompany the patient to doctors’ visits to serve as another set of “ears” and to take notes for later reference
•    Picking up medications at the local pharmacy and discussing any concerns with the pharmacist
•    Other responsibilities may be financial or emotional in nature or can involve advocating for the patient

CGMW: What are the coordinated care programs Medicare is implementing? How do they work?
Boyko: In order to keep its costs down, Medicare has developed coordinated care programs. The goal of these programs is to not only improve patient care but to reduce hospital readmissions, prevent medical errors and ensure that patients are receiving the “right care at the right time in the right setting,” according to Medicare.gov.

Medicare’s coordinated care programs include Accountable Care Organizations (ACO) and the Comprehensive Primary Care initiative.

CGMW: What is an Accountable Care Organization (ACO)?
Boyko: The short answer is that an ACO is a healthcare organization – comprised of doctors, hospitals and other health care providers – that aims to keep health care delivery costs down by tying the cost of care to the quality of care.

The more detailed answer is that an ACO ensures that all components of a patient’s medical team – including doctors, specialists, hospitals, home health providers and more – are working together to ensure that the health and safety needs of the patient are being met. This results in lowering costs for care as well as limiting duplication of services.

ACOs were formed in response to the national deficit, with reducing Medicare costs a “prime target”, according to Kaiser Health News, which also indicates that “ACOs are projected to save Medicare up to $940 million in their first four years.”

Finally, an ACO leads to better care for the patient. “When your health care providers have access to your health information and are able to share that information with one another, they can give you better, more coordinated care. Each of your health care providers won’t only know about the health issues that they’ve treated, they’ll have a more complete picture of your health through communicating with your other health care providers. When your health care providers participate in an ACO, you should see better, more coordinated care over time. With an ACO, you’re the center of care, and your satisfaction is one of their goals,” according to the Centers for Medicare & Medicaid Services.

CGMW: What is the Comprehensive Primary Care initiative?
Boyko: It’s an initiative between Medicare and health insurance plans – both on the state and commercial levels – that offers bonuses to primary care physicians who are successful in coordinating their patients’ care.

Medicare says that, as a result of the collaboration, doctors will get the help they need to “manage care for patients with high health care needs; ensure access to care; deliver preventative care; engage patients and caregivers; and coordinate care across the medical neighborhood.”

These goals can be achieved through the use of electronic medical records and collaboration across the entire care team.

CGMW: Are there other care coordination programs a caregiver should know about through MassHealth, the Affordable Care Act, insurance companies, etc.?

Boyko: Massachusetts’ One Care, for those who qualify, provides a care coordinator to help patients obtain the most appropriate services based on their needs.  For information on One Care Plans, and to find out which plan may be appropriate for you or a loved one, visit the One Care Plans page of the Massachusetts Department of Health and Human Services. Also check out BayPath Elder Services‘ One Care programs for more localized information for MetroWest.