Aligning Care Coordination Work Amid Healthcare Workforce Shortage

August 15, 2022 - Healthcare organizations nationwide are staring down competing priorities to increase care coordination for complex patients while staving off provider burnout for a dwindling workforce.

It can sometimes feel like those goals are mutually exclusive. Supporting care coordination and patient outreach within the community is possible with a big enough and well-trained social worker and patient navigation workforce.

“The bigger challenge always was how to reach a certain kind of population, which it's not easy to access them by letters or phones,” Azer Rezk, clinical administrator at Metropolitan Family Medical Clinics in the San Bernardino, California, area, told PatientEngagementHIT. “It is also an issue for health plans because these people don't have access to care, or some of them just are using the hospital as their primary care, even though we can help them with that too.”

Strong patient engagement, outreach, and care coordination are necessary for connecting traditionally underserved folks to care. Individuals experiencing homelessness, drug abuse or misuse, and who were recently incarcerated often have a hard time connecting to care.

And when Rezk and his team do see these folks in the clinic, providers want to be able to engage them more deeply, helping with care management and giving patients a place to go regularly to keep any chronic illnesses and behavioral health issues a bay.

But comprehensive patient engagement needs a big, specialized team, and provider workforce numbers don’t lie. In May 2022, the Nurse Salary Research Report found that more nurses—the very people often helming care coordination efforts—are considering leaving their jobs. Healthcare has been hit hard by the great resignation, leaving some providers’ plans for population health and patient engagement in a lurch.

“We need more social workers and behavioral health people who can follow up with patients and can reach out in person to them, too,” Rezk explained.

“As clinics, we only service people once they come to the office. We’re trying to reach this segment of the population, who are more homeless or drug users or just frequent visitors to ER, who really don't get enough care from us, and also cost the insurance company way much than they should.”

Particularly, Metropolitan Family Medical Clinics needed more social workers, more patient care navigators, and more advanced practice providers like nurse practitioners. These folks tend to take on much of the care coordination duties that go hand-in-hand with whole-person care.

Between their respected status in the community and ability to forge deep relationships with patients, these medical professionals are able to help patients navigate the complexities of managing multiple physical or behavioral health needs alongside their social needs.

But like Rezk’s organization, not every clinic can hire them.

Rezk and his team got a reprieve when the HMO with which the clinic primarily contracts introduced the Enhanced Care Management (ECM) program in partnership with Pair Team, an organization that provides a mobile care team to supplement care coordination. The ECM program is currently tailored to individuals experiencing homelessness, folks who use or misuse drugs, those who frequently visit the ED, and some justice-involved individuals who may also fall into any of the aforementioned categories.

Metropolitan Family Medical Clinics identify eligible patients through a referral from the HMO, partnership with area emergency departments, and their own interactions with patients who make their way into the clinics. Patients elect to join the ECM model, a decision Rezk said is usually pretty easy once patients know about the added benefits of care coordination and management.

“Three patients signed up on the first day because it doesn't take anything from patients, just adding all this extra help that they're getting if they qualify,” Rezk said.

That help includes community outreach, 24/7 access to the mobile care management coordinators, behavioral health specialists, and nurse practitioners.

“They also get access to our offices, which are walk-in offices,” Rezk added. “They can come anytime if they really want to see a provider face-to-face. We’re just trying to get them better-quality services.”

This program requires a lot of moving parts, Rezk acknowledged, needing input from the HMO, the ED, and Metropolitan Family Medical Clinics itself. But that orchestration was easy to achieve because all of those stakeholders are ultimately looking for the same thing.

The HMO wants to cut costs. The ED wants to keep volumes down so it can treat truly emergent cases. And Rezk’s team wants both, plus high-quality care for all patients.

In terms of collaboration with the ECM program itself, Rezk said it has been important to work side-by-side and share resources to make sure everyone can do their job.

“We both are completing each other. We're not just doing the same thing,” he pointed out. “That, too, makes life a lot easier because we couldn't have done the program without them because we don't have the social workers as part of our clinical work, and also, we don't have all the outreach help we have with them, too.”

“The program is monitored by our physicians and also by the HMO company, so we are always working hand-in-hand,” Rezk added.

At the time of the phone interview, Rezk said about 105 patients had enrolled in the ECM program, with 30 percent being homeless, 30 percent being frequent ED uses, and the rest having multiple chronic illnesses. Ultimately, the organization thinks it can get around 750 people in the ECM program and hopes to one day expand eligibility criteria.

“It's kind of expensive to provide all kind of services, but really in long run, it really saves money for everybody,” Rezk concluded. “Just keep patients healthy, and keep them out of the hospital, and feeling better. It's a very quality-oriented program, which helps everybody.”