Service Coordination in Healthcare Industry

Quality healthcare is one of the most important factors in how individuals perceive their quality of life. In most countries, alongside the economy, it is the major political issue. In some countries, such as the UK with the National Health Service (NHS), the healthcare delivery organization is a part of their national identity.

The success of any treatment option depends on effective communication and consistent follow-through. That’s why it’s critical when patients and public need hospital care.

At each step, doctors, nurses and support staff need to make sure that they understand their treatment. Confusion about care instructions or gaps in care is needed to be quickly identified and resolved. Staff can coordinate doctors to support the treatment process by providing:

  • Preadmission counseling
  • Inpatient care advocacy
  • Discharge planning
  • Readmission prevention program
  • Prescription and rehabilitation information

The results include higher quality of care, fewer complications and decreased hospital readmissions following surgery.

 

Service Coordination functions

Some major service coordination functions are listed below:

  • Plan Development Assessment – A person centered planning process that identifies the person’s need for assistance in gaining and coordinating access to care and services.
  • Plan Development – The process of developing a plan that links a participant to needed medical, psychiatric, social, early intervention, education, and other services.
  • Referrals – It links the participant to needed medical, psychiatric, social, early intervention, education, and other services.
  • Monitoring – Monitoring the plan to assure participant has been linked to needed services identified on the plan. The service coordinator needs to coordinate and adjust the plan as necessary.
  • Crisis Assistance: Providing crisis assistance and may seek involvement of Department’s crisis prevention team.

 

Core Responsibilities

The staff needs to serve as a specialist to systems’ staff, providing information on a wide range of mental health topics.  They are also responsible in monitoring and linking of services identified as determining the strengths, needs, abilities, and preferences of the patient, child and family. They need to provide clinical support to the individual and family to help them cope with stressors related to serious emotional disturbance.

Staff needs to actively collaborate with other systems’ staff, doctors, physicians and specialists regarding assigned individuals and their families, participate as a member of the multi-disciplinary team to advocate for the mental health needs of the child/family.

In the healthcare industry, it is important to monitor family participation and progress in organized treatment programs to assure the planned provision of service according the individual’s treatment plan; also they should participate as a member of a multi-disciplinary team in all treatment plan reviews of patients.

Few internal service coordination aspects that needs to be followed by staff, are listed below:

  • Collaborate with families and systems to develop Individualized treatment Plans.
  • Provide crisis intervention and critical incident stress management services.
  • Provide parenting education.  (Family System Model)
  • Maintain contact with patient who are hospitalized/respite/residential and participate in discharge planning and necessary collateral contacts.
  • Provide anger management skill builder.
  • Provide communication skill builder.
  • Consistently meet 100% productivity.
  • Meet the unique cultural needs of each patient and family member.

 

Service Coordination Features

Desired attributes consistently rise to the surface that can be evaluated on the basis of staff, resources, demographics, target audience and many other factors. Few of them are listed below:

  • Developing guidelines, performance measures and quality indicators.
  • Identifying and addressing opportunities for quality and efficiency improvement.
  • Finding tools and advice for achieving goals.
  • Educating practice administrators and patients
  • Comprehensive and flexible benefits and treatment tailored to people with complex medical needs.
  • Timely access to knowledgeable, high quality physicians.
  • Integrated care management teams in constant communication with each other and the person with complex medical needs.
  • Financial incentives aligned with providing high quality care.
  • Live at home when medically appropriate.
  • A single person who assembles resources and advocates for the participant.

healthcare

 

Key Issues and Concerns

Inappropriate Services Delivered

Often due to the very nature of the economic incentives to the payors, practitioners and the patients, the focus is on the quantity of delivery and not on the quality. There simply are no structures to assess the outcome of healthcare on patients, performance of providers or the administrative efficiency of payers. This “fee-for-service” model leads to several unnecessary and inappropriate services prescribed to the patients.

Finding Qualified Staff

Given this increase demand, health care agencies will face the challenge of finding qualified staff.  Unfortunately, current estimates show that demand for capable individuals (which is already far above the supply) will continue to lag behind growth for at least the next five years.

But there is hope.  There are an estimated 1.3 million health aides currently in the process of entering the job marketplace and 50% growth is expected on top of that figure by 2018.  That makes this job one of the fastest growing fields in America today.

That doesn’t mean that these qualified applicants are distributed evenly, though.  The highest concentrations are – as expected – on the West and East Coast, with a vast gap in between.  The good news is that struggling home health agencies will have more potential applicants to help fill those jobs.  The bad news is that it doesn’t look like all of those open positions will be filled immediately.

Advances in Technology

The health care industry is in the middle of a tremendous technological revolution. Older, outdated systems are being replaced with faster, less-intrusive and more powerful equipment.  From health monitoring systems that integrate with hospital networks to mobile pharmaceutical administrations units and beyond, technology is expanding at an ever-increasing pace…

And the health care industry is struggling to keep up.  Learning how to correctly and effectively use these new gadgets takes a considerable investment of time and effort.  While some agencies are leading the pack, others are lagging behind – put off by either the added cost of the added hassle.

Keeping Qualified Staff

But despite challenges in this area, payment is the key component to building a qualified staff for many home health care agencies.  Shocking figures reported in the Lubbock Avalanche-Journal last year show that nearly half of all home care workers live at or below the poverty line.  Many rely on government benefits such as food stamps and make as little as $9.70 per hour.  According to Department of Labor statistics, that’s 4 cents less per hour than fast-food workers.

That cannot be allowed to continue, but many agencies simply cannot afford to pay more.  While technology may be able to pick up some of the load (at the cost of individual jobs), there remains no clear cut answer as to how to build better wages for the backbone of this industry.

Medical Fraud

Medical fraud primarily emanates from billing of unnecessary healthcare services and healthcare services which are not actually rendered. The annual cost to tax payers due to medical fraud is estimated to be around $ 80 Billion according to FBI. Some of the areas of medical fraud are mentioned below.

  • Billing for services not rendered
  • Upcoding of services
  • Upcoding of items
  • Duplicate claims
  • Unbundling
  • Excessive services
  • Unnecessary services
  • Kickbacks

 

High Administration Costs

Often a significant amount of effort of Physicians and healthcare workers is spent in administrative tasks rather than care delivery. This primarily due complex set of regulations of reporting and compliance which hinders clear capture of data in a user friendly way.

The administration costs in healthcare industry are significantly higher than the costs incurred in corresponding functions in other industries. On the payer side also increased administration costs of BIR (Billing and Insurance Related) processes like claims processing and eligibility of providers. Frequent claim rejections, under payment and reclaims lead to a high administrative overhead on the part of the payers.

According to an estimate on an average level approximately 11% of the premium of commercial health insurance products is spent on administration. While the industry leading payers adopting technology and best practices succeed in keeping these expenses down to about 8%. On a pan industry level this amounts to saving of around $20 Billion.

Lack of Transparency

Often thereis complete lack of reliable medium for exchange of information like the actual cost of care, expenses of resources required in the delivery. For a market driven healthcare system like US , free and reliable flow of information is critical to enable consumers to make informed decisions. Transparency of cost and outcomes will also increase the decision accuracy of the providers leading to overall improvement in the quality of care.

Inefficiency

The system fosters several inefficiencies due to the managed care model, where services prescribed are based on factors like insurance coverage, deductibles etc… rather than the general wellbeing of the services seeker. Due to the lack of a clear communication channel between various providers, payers and consumers, often repetitive testing prescriptions make the scenario complex for the patients.

 

Conclusion

Based on our experience with the pilot programs, comprehensive service coordination appears to be a promising approach for people with disabilities and other complex medical needs. It holds the promise of maximizing the quality of health and life for individuals receiving services. For providers it offers a way to enhance their delivery systems. And for payers it may have the potential to use fiscal resources more effectively.

As in any industry that’s booming, the key to success is adapting on the fly.  There’s no real time to sit down and plot out a ten-year business plan because, by the time all the estimates are in, the environment has changed significantly.  Businesses must go with their best guesses and hope for the best.   Unfortunately, this means that many will fail.  However, it also means that a few will be extremely prosperous.  The vast majority will fall somewhere between these two polar opposites.

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