As changing clinical roles and technical innovations require care coordination to be approached as a team sport, it’s important to encourage provider accountability, consider the social determinants of health and foster technical innovation, said health care leaders at the inaugural AHA Executive Forum in Chicago. 

Karen Miller Boudreau, M.D., senior vice president of enterprise care and management coordination at Seattle-based Providence St. Joseph Health, explained that care has gradually been “chopped up into much smaller pieces” as hospital leaders strive to care for more patients, more efficiently. Clinicians must therefore manage more moving parts, which has made their roles more complex. 

But with the field challenged by a lack of interoperable tools, physicians — who already are burning out in record numbers — often are tasked with picking up the administrative slack. This also is true for case managers and clinical teams, who must contend with disparate information. 

“[Care management systems are] still designed mostly to document single interactions at the time, not from a care management perspective,” Boudreau said. 

John Glaser, Cerner’s senior vice president of population health, noted that although “interoperability is still really painful in lots of ways, some of the technology is still early on” and shows promise.

And, as the equipment behind electronic health records and telehealth becomes more connected, aggregating and sharing data and care plans will get easier, he said.

On top of connectivity problems, misaligned payment incentives present technical challenges.

“The innovation is out ahead of the regulation, and that makes it difficult,” Boudreau said. “Two-thirds of our payer sources are government payers, and those don’t always work with some of the innovations.”

As leaders rethink the care continuum, they must remember to consider the social needs of patients and design their care plans accordingly, said Rachelle Schultz, president and CEO of Winona (MN) Health. “If the patient can’t afford their medication, the physician designing a beautiful care plan won’t matter,” she said. This is where involving a range of individuals in the care plan — such as social workers and behavioral health professionals — makes a difference.

Schultz said that, in rural communities in particular, care has expanded outside of the hospital walls and into the community. It certainly has been a priority at her organization.

“When we looked at why people continue to come back to the emergency room — and we really got close and personal with patients about that — it really was issues of housing, food, employment, dysfunctional family situations [and] social isolation,” she said.

Schultz and her team made the conscious decision to coordinate this added dimension of health as a proactive way to addresses patients’ needs from the outset.

“We see ourselves more as a catalyst for a lot of these other organizations in the community, to [invite them to] help,” she said. “We’re trying to get to ‘what are those root causes?’ and then see how we can coordinate around them.”

Boudreau, who has seen progress in her community by taking a similar approach, said it was “astonishing” how much of a difference addressing social determinants could make. Because of this, it’s something Providence St. Joseph’s innovation team is prioritizing.