Building Blocks to Improve Care Coordination and Patient Engagement

    Consequences of Fragmented Care

    Fragmented care has a direct influence on the patient experience and care quality. Consider the multi-faceted cost and quality impact of fragmentation:

    75% increase in overall healthcare costs i

    2x as many primary care visits and 6x as many specialist encounters ii

    7% greater likelihood that care deviates from best practices iii

    The care fragmentation experienced by today’s patients is often caused by ineffective transitions of care due to a siloed patient story, lack of a longitudinal care plan, and suboptimal use of technology.

    Care coordination overcomes care fragmentation

    Given the complexity of today’s healthcare system, many providers face challenges in actualizing a sustainable care coordination strategy. Yet, there is ample opportunity to overcome these challenges and deliver better care across the patient’s journey by embracing best practices for care coordination.

    The most effective longitudinal care coordination models are patient-centered, designed for optimal information sharing between clinical teams, and include six key elements as defined in the eBook.

    6 Elements


    Patient and Family Engagement

    The patient story forms the foundation of care coordination. This narrative is built from strong partnerships between clinicians, patients, and their families, and reflects a deep understanding of care preferences, values, and goals.

    Once established, the patient story provides the basis for “whole person” care planning. This approach considers both medical needs and social determinants of health (SDOH) – as these non-clinical social, economic, and environmental factors impact health by as much as 50%.

    Your care team can bring the patient story together and foster a patient commitment to self-care by:

    • Focusing on what matters most to the patient and family

    • Engaging the patient as an active partner

    • Understanding and aligning interventions with patient goals

    • Identifying and addressing SDOH

    • Communicating consistent information

    • Leveraging technology for meaningful information-sharing through preferred channels


    Longitudinal Care Plan

    Conceptually, a longitudinal care plan (LCP) provides a one-stop central hub for accessing the full patient story and all information needed to support optimal care transitions. A longitudinal care plan is a holistic, dynamic, and integrated plan that documents important disease prevention and treatment goals and plans. An LCP is patient-centered, reflecting a patient’s values and preferences, and is dependent upon bidirectional communications.v The LCP aligns the care team around the patient’s goals and preferences.

    The LCP benefits the patient and the care team. Patients are reassured that their care teams understand their unique needs and will approach care with a personalized plan. Confidence in their care providers can help motivate them to follow their care plan. And clinicians benefit from the shared expertise of the entire interprofessional team contributing to the care plan.

    For maximum impact, ensure your patient’s longitudinal care plan is:

    • Driven by the patient’s goals

    • Focused on wellness and disease self-management

    • Supportive of team-based care and communication

    Download the eBook to read about the rest of the 6 Elements.

    Download eBook

    Six Keys to Effective Longitudinal Care Plans

    Point of Care Tools

    Elsevier’s Care Planning promotes team-based, patient-centered care throughout the patient’s entire journey, driving more standardized and safer care.

    Elsevier’s PatientPass delivers current, evidence-based patient education, personalized for each patient’s delivery preferences, health literacy and health status.

    With Elsevier’s Care Planning and PatientPass comprehensive patient care and education solutions, you can promote team-based collaboration that contributes to more consistent care and a better patient experience, enable clinicians to find and refer the right education to keep the patient engaged in their treatment plan, and derive insights into what your organization can do differently to deliver better care to your community.

    Contact us to learn more

    i[EJ(H1] Artiga, S. A., & Hinton, E. H. (2018, May). Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. KFF.

    ii Frandsen, Brigham R.; Joynt, Karen E.; Rebitzer, James B.; Jha, Ashish K. “Care Fragmentation, Quality, and Costs Among Chronically Ill Patients”.The American Journal of Managed Care. Managed Markets Network. 14 May 2015.

    iii Dykes, P. C., Samal, L., Donahue, M., Greenberg, J. O., Hurley, A. C., Hasan, O., O’Malley, T. A., Venkatesh, A. K., Volk, L. A., & Bates, D. W. (2014). A patient-centered longitudinal care plan: vision versus reality. Journal of the American Medical Informatics Association, 21(6), 1082–1090.

    v Dykes PC, Samal L, Donahue M, Greenberg JO, Hurley AC, Hasan O, O’Malley TA, Venkatesh AK, Volk LA, Bates DW. A patient-centered longitudinal care plan:vision versus reality. J Am Med Inform Assoc. 2014 Nov-Dec;21(6):1082-90. doi: 10.1136/amiajnl-2013-002454. Epub 2014 Jul 4. PMID: 24996874; PMCID: PMC4215040

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