July 20, 2020
Care coordination at Texas Children’s – an already challenging job – has become that much more challenging as COVID-19 cases surge in the Houston area. But in true #oneamazingteam fashion, the team of 52 has risen to the occasion and continues to support their multidisciplinary counterparts.
“The entire team is working remotely,” said Jennifer Thorpe, Director of Care Coordination at main campus. “However, with the help of technology and innovative leadership we are remaining successful.”
The department has two primary responsibilities – first, patient care coordination. This means to effectively prepare families for condition management outside of the inpatient setting. The team focuses on timely and safe discharges that prepare families for appropriate management of their conditions.
Secondly, the team is focused on Utilization Management, which is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities. In other words, how are services, procedures and facilities being used by a patient? And are these uses necessary, appropriate and efficient? The team focuses on centralized utilization reviews, length of stay management, payer relationships, daily review of observation patients, and authorizations.
“The ability to deliver exceptional care in an effective and cost-efficient way is always the first priority for Texas Children’s,” Thorpe said. “Care coordinators are at the heart of that priority and our resolve is stronger than ever.”
While Thorpe’s team serves main campus patients, there are care coordinators across the system including the health plan team lead by Ashley Simms, the West Campus team lead by Kara Abrameit and The Woodlands team led by Julie Barrett. They all work closely to support one another.
The Department of Care Coordination also has access care coordinators located in the emergency center at Main, West and Woodlands campuses. The access care coordinators focus on patient access at the point of entry, the review for appropriate status, the coordination of admissions, transfers, direct admissions activity at specific locations and partnering with interdisciplinary care teams.
Intended outcomes as defined by Care Coordination success measures are:
- Decreased Emergency Center admissions for established patients with chronic conditions.
- A decrease in duplication of efforts for the same patient across the system.
- A tracking of referrals to community based organizations with appropriate follow up and gap closure.
- The use of predictive analytics to decrease high cost care and unnecessary utilization of services based on what has happened to provide a best assessment of what will happen in the future.
- Identification of off the scale “outliers” to rising risk conditions that drive cost and work across the system to close care gaps.
- An increase in linkage to community based organizations for social determinants of health and tracking of ‘community’ data alongside clinical and claims data to measure intervention care impact on patients with chronic diseases.
- Management of length of stay via the use of the 3M bi-directional interface.
- The utilization of patient stratification to look for and intervene on high-risk or determined risk families.
Racial justice in health care
In addition to COVID-19, care coordinators are also positioned to respond to our society’s recent focus on racial and social justice. The Department of Care Coordination reports to Senior Vice President Tabitha Rice. Tabitha lives the core values of Texas Children’s and believes in racial, religious, and gender equality. This is evident in her ongoing efforts to champion change as well as the department’s response to identified socioeconomic barriers in vulnerable and underserved populations. As part of the department’s response, they have reignited efforts to adopt a new electronic platform called “Aunt Bertha,” which serves as a portal for valuable resources.
“A large number of racial minorities are included in groups that face socioeconomic issues,” Thorpe said. “When you are facing challenges with literacy, parenting, employment, or live in a food desert, this can affect your overall ability to stay healthy.”
With just a click of a button, Aunt Bertha would allow families to access social service information such as rental assistance, food assistance, mental health services and much more. Thorpe said there are discussions about how to integrate this platform with Epic and MyChart.
The future of care coordination
Prior to the COVID-19 pandemic, the department had excitedly partnered with Dr. Jennifer Sanders, Gail Vozzella and Dr. Michelle Lyn on the initial phases of the Care Coordination Center, a separate Texas Children’s facility that would serve as a care continuum hub between inpatient and outpatient. Phase one goals for the Care Coordination Center include:
- All non-TCHP Tier 1 Star Kids patients discharged from an inpatient stay at the hospital will receive a standardized discharge follow-up phone call within 72 hours to ensure they understand their discharge instructions and follow-up visits.
- Ensuring continuity of care across health care settings by establishing a standardized process to ensure appointments are made prior to discharge.
- Centralizing the process of obtaining Durable Medical Equipment to meet the therapeutic benefits of patients in need and enhance provider satisfaction.
- The aim of the Care Coordination Center is to offer one consistent place for patients, families, providers or designees to receive 24/7 high touch coordinated services for recipients of healthcare within the Texas Children’s system. Although the timeline for moving in has been adjusted, those plans are still in the works.
Thorpe reminds the organization that although there are teams 100 perent dedicated to this work, Care Coordination is ultimately the responsibility of both clinical and non-clinical employees throughout Texas Children’s.
When care coordination is done well, we are all adhering to the key elements:
- Having a shared care plan that forces us to think through responsibilities and potential problems ahead of time.
- Communicating with patients by explaining treatments, procedures and necessary follow-up actions.
- Communicating between providers and care givers by telling all the details of the patients’ story when performing a hand-off.
- Transitioning a patient efficiently between areas within our system or between their stages of care.
- Organizing a patient’s care for their convenience by taking into consideration things like scheduling, transportation, supplies, medications, etc.
- Using community resources effectively.
Multidisciplinary team members can access Spok to identify their unit’s assigned Care Coordinator each day. The Care Coordination team is available Monday through Friday 8 a.m. to 5 .m.p and on call until 11 p.m.
For more information about Care Coordination, read a story previously posted at: https://texaschildrensnews.org/coordinating-the-care-of-our-patients/
View team photos at the links below:
Care Coordination Leadership Team
Access Care Coordinators
Inpatient Care Coordinators
Utilization Management Care Coordinators