Dr DJ Hamblin-Brown, CEO, CAREFUL, UK
Clinical care coordination is the process of organising and coordinating healthcare and related services for patients, particularly those with complex medical conditions. It involves ensuring that all necessary medical services, tests and treatments are provided in a timely and efficient manner ensuring that patients receive the right care at the right time, in the right place, and from the right provider.
Effective clinical care coordination is therefore crucial for improving patient outcomes and reducing healthcare costs. It requires a multidisciplinary approach, from doctors, nurses, allied health professionals, social workers and others.
The author is an emergency medicine doctor with senior management experience in the acute sector. This article builds on his direct experience of problems of care coordination as both a physician, a relative and carer, as well as a healthcare leader.
Three cases
CASE 1:
A 45-year-old man with crushing central chest pain is admitted to the emergency room with suspected MI. The patient's blood sugar level of 29 mmol/l suggests that type 2 diabetes is a likely precipitating factor. The patient’s relatives report that his HbA1c was measured at 6% 3 years ago but had not been repeated, as required by guidelines.
Discussion: The prevalence of T2 diabetes is growing exponentially worldwide and presents a significant public health problem in many countries as they develop and age. Who was responsible for ensuring that this test was repeated? Had the patient moved under the care of different care organisation? How the patient was made aware of the original test result.
CASE 2
A 29-year-old woman, 23 weeks into her second pregnancy is admitted to the ED with collapse and sepsis. She has a positive ‘flu test. Her baby was born with extreme prematurity, and she spent two weeks in ICU. Her family remember that she was offered a ‘flu vaccine but failed to attend her appointment.
Discussion: Pregnant women have poorer outcomes with influenza, as do their babies. No adverse effect at the population level has been observed from the vaccine. Who knew that this woman had failed to attend her vaccination appointment? Whose responsibility was it to follow up?
CASE 3
A 75-year-old bed- and chair-bound man is re-admitted to hospital with sepsis caused by a worsening of a large sacral bed sore. He had been discharged three weeks earlier following an admission for a fall. The dressing had not been changed while he was at home.
Discussion: Frail elderly patients are at risk of deterioration following discharge for a number of reasons. Discharge instructions can be confusing or absent in many cases. Community nursing colleagues and families are often not aware of the care plan put in place by the discharging hospital. Who was responsible for managing the pressure ulcer?
Read more to know point to point about: The Challenge of Clinical Care Coordination
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