Posted September 20, 2018

The Case for Care Continuum Leaders

By Matthew Bates, MPH

As consumers are increasingly seeking healthcare outside the four walls of the hospital, there is a greater emphasis on coordinating care. With the introduction of the transitions of care domain in the HCAHPS survey, additional focus has been placed on discharge from acute care, but that is only one of many transitions patients may face as they seek treatment.

Interestingly, most organizations do not have horizontal leaders who are responsible for overseeing coordination between facilities and providers to ensure patient care is seamlessly managed. In many cases, consumers access different points of service within a system and are treated as a new patient every time, filling out new intake forms or detailing their medical history during each visit. We’ve created comprehensive health systems without creating the leadership infrastructure to truly support them.

The goal of healthcare should be to provide the right care at the right time and the right place for each and every patient. With the “substantial overuse, underuse and misuse” of services that define the healthcare industry, care coordination is paramount to executing on a consumer-centric strategy to deliver exceptional patient care.

Horizontal Care Continuum Leaders

To succeed in coordinating care, I recommend seeking out leaders with the vision and ability to understand the entire continuum. The creation of a new position whose job it is to identify and remove barriers will proactively promote coordinated care.

This c-suite role, reporting directly to the system chief executive officer, is an evolution of traditional service line leaders. Traditionally, these leaders (usually physicians or nurses) have been responsible for care coordination across their particular areas of focus, but without a 360-degree view of the entire system. Essentially, these leaders were catalysts to conversations about care coordination and could offer advice, but when it came down to making change, their hands were often tied.

Care continuum leaders take that model one step further by taking on management across the entire healthcare continuum, from primary care clinics to post-acute care such as rehabilitation hospitals, skilled nursing facilities and even home health. Additionally, they are not only advisors and coaches, but are also accountable for executing a consumer-centric coordination strategy that values patients and outcomes over volume. This shift to value over volume is an industry trend we are seeing take root across the country.  In fact, most top-performing Medicare accountable care organizations (ACOs) have succeeded in decreasing costs while maintaining or increasing quality specifically by actively managing and reducing the utilization of high-cost visits to emergency departments, hospitals, rehabilitation clinics and skilled nursing facilities.

The goal is to take the tenets of care management and apply it across the entire continuum of care. Rather than following an individual patient throughout their treatment plan, the care continuum leader takes a more holistic view of the ways patients interact with the system, identifying barriers to seamless care and removing them.

Additionally, these leaders would be responsible for ensuring organizational goals are not only cascaded vertically, but horizontally throughout the organization, as well. The primary barrier to horizontally managed care is that typically the different players within the system are not incentivized in the same way. For example, primary care is likely incentivized to reduce the amount of acute care patients need while the emergency department is likely incentivized by volume. When this is the case, cross purposes are at work, setting all sides up for failure. By taking a system view of care delivery, the entire organization, regardless of specialty or role, works toward the same goal – providing the right care at the right time and place to do the right thing for patients.

Potential Benefits

When executed well, care coordination can help to decrease healthcare costs, increase quality and improve clinical outcomes.

  • The primary benefit for healthcare systems is delivering on their brand promise by creating a positive patient experience. When patients are treated as if they matter and provided with what they need and want, it creates loyal consumers who will return to seek treatment in the same organization for years to come. Additionally, care coordination has been shown to reduce readmissions and improve patient experience, both of which carry a financial benefit for the organization.
  • For providers, care coordination can lead to improved job satisfaction and decreased burnout. Reconstructive plastic surgeon Simon G. Talbot and psychiatrist Wendy Dean said that burnout in healthcare arises from care providers’ “moral injury” over the conflict between what they are being asked to deliver on for the organization for which they work and what they know is right for patients. When physicians provide coordinated, high-quality care that is in the best interest of patients, this eliminates the “moral injury” and increases provider satisfaction.
  • For patients and families, the benefit is improved quality and clinical outcomes. When providers work together to streamline care, coordinate treatment and deliver optimal results, patients win because they get exactly the right care as dictated by their individual health and social requirements.

The future of healthcare will be led by savvy leaders who understand that when care is seamless and well-coordinated, all stakeholders benefit. If the goal is to provide truly exceptional patient care, that can’t stop at the four walls of the hospital. The expansion of our health systems and the continuum of care dictates the need for executive oversight of patients’ progression from pre-acute to post-acute care and everything in between.


  • Matthew Bates

    Matthew Bates, MPH

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