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Care coordination software is a branch of long term care software used in nursing homes and skilled nursing facilities to automate their care coordination processes by improving the communication process, thus freeing nurses to focus on what matters: getting the best long term care outcomes.

Nurses are the ones who coordinate resident care, which means they must share resident information with other members of the resident care team, collaborate with providers to create a resident care plan, and support residents in managing their healthcare goals. By using Care coordination software, care providers can access a holistic overview of a patient or resident’s care progress, thus enabling patients or residents to receive timely, care-related information from their providers. 

The care coordination process can be reduced to the following easy steps, as noted by Sidmartin Bio:

  • Data Analysis: Data, such as medical records, are received by providers and is analyzed so that providers can predict the care needs of a future resident.
  • Selection: Once data has been analyzed, the provider then selects residents based on the services they provide.
  • Assessment: Once a resident has been selected, a full assessment of a resident’s status and needs is conducted.
  • Planning: After resident needs have been understood, the planning phase begins with an eye toward their care requirements.
  • Interventions: During this stage, the nursing team will consider all possible interventions to address the problems, goals, and needs of the patient or resident.
  • Evaluation: In this final step of the care coordination process, data analysis is revisited for the purpose of improving patient outcomes.

Why Care Coordinators Need a Care Coordination Platform

A patient care coordinator will typically be the primary person interacting with the long term care software when a nursing home uses a care coordination platform. A patient care coordinator—also known as a care coordinator—is a healthcare professional who listens to long term care residents and their families to ensure that residents’ needs are met and that they get the best care possible.

Bryant & Stratton College notes that the responsibilities of a care coordinator include:

Nurse and physician filling a resident chart in care coordination software.
A care coordinator ensures that residents’ needs are met and that they get the best care possible.
  • Analyzing data and making entries
  • Managing resident accounts
  • Ensuring compliance with long term care standards and regulatory requirements
  • Coordinating with teams to ensure each resident gets the best care possible
  • Scheduling outpatient appointments
  • Scanning documents into resident charts
  • Meeting with residents and families to discuss treatments, procedures, medications and continuing care
  • Setting quality assurance goals and best practices
  • Locating funding for special procedures 

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Care coordination software helps to automate most of the above processes while minimizing errors during care coordination. Using a care coordination platform will help long term care providers tackle coordination challenges while delivering the best care outcomes to their residents. There are however notes that there are five major obstacles to care coordination as noted by Medical Economics:

  1. Long term care EHR coordination: Facilities that use different long term care EHR software may not integrate properly as they have different data formats and code bases.
  2. Dealing with specialists: Primary care physicians report that one of the biggest challenges to care coordination is working with specialists. Some specialists may not want to cooperate with primary care physicians.
  3. Payments: Reimbursements are not always easy, and primary care physicians can face challenges in getting reimbursed for care provided.
  4. Patient or resident participation: Sometimes, residents’ input is overlooked during care coordination. Without resident input, participation and coordination, care outcomes cannot be achieved.

6 Benefits of Care Coordination Tools

Before we talk about the benefits of care coordination tools, we must first distinguish between care coordination software and care management software. According to Health IT Analytics, care management mainly occurs in a hospital setting, while care coordination takes place in a myriad of settings like nursing homes and SNFs. Hence, care management software is more often used in hospital settings. Meanwhile, other care coordination platform, like long term care software, will feature modules that facilitate the checking of ADLs and SNF bed availability.

So what are the benefits of care coordination software? According to Thorough Care, they include:

1.     Consolidation of Resident Information

Image showing the difference between care management and care coordination software or care coordination tools.
Care management mainly occurs in a hospital setting, while care coordination takes place in a myriad of settings.

Although laws have been passed that require healthcare providers to move to electronic records, this does not mean the information is always transferred from acute to post acute care smoothly. The best care coordination software, of course, consolidates a resident’s medical history and other information in an organized manner, enabling nurses and other healthcare professionals in long term care facilities to access the information stored in a centralized location.

2.     Improved Care Coordination

This is the main benefit of using care coordination software in long term care facilities. Communication between the care coordinator, the physician, and the resident becomes seamless, leading to better care plan creation, reporting, flagging, and ultimately better care outcomes for the resident.

3.     More Patient and Resident Engagement

The best care coordination tools make it easy for residents to be heard. When care coordination software is built with a patient-centered care approach in mind, patient and resident engagement increases. With patient-centered care, patients and residents actively participate in their medical treatment in close cooperation with their physicians. This gives residents the feeling of being heard when it comes to their care plan and treatments.

According to NCBI, patient-centered care is associated with higher levels of patient satisfaction, better care outcomes, cost-effectiveness, and patient adherence to physician-recommended lifestyle changes and prescribed treatments.

4.     Improved Efficiency

Care coordination software can improve the efficiency of a skilled nursing facility by automating processes in a long term care EHR that would otherwise be done manually. Maintenance of resident records can be a time-consuming activity for nurses, and so can communicating with external suppliers. Care coordination tools can streamline these tasks by enabling the quick retrieval of resident records, following up on communications with an external supplier, and making automated billing claims. This frees up nurses so they can spend their time caring for their nursing home residents.

5.     Improved Accuracy

Good documentation is essential in long term care. This is because documentation of claims, billing, and services provided to residents in a long term care software system are needed to stay compliant with CMS. Care coordination software can automate the documentation and reporting process, making it easier for nursing homes and SNFs to stay compliant with regulations, should an audit occur.

6.     Risk Stratification and Predictive Analysis

With all the information one can receive and organize using care coordination software, nurses and physicians can perform risk stratification and predictive analysis in their nursing home software system. According to Amitech, risk stratification is an analytical method where patients are divided into different levels of risk in regard to chronic diseases. This enables nurses and physicians to dedicate their time with greater precision for better care outcomes. When employing risk stratification, there are some tips worth noting:

Nurse reading a resident's chart on a care coordination platform.
Long term care facilities should have a plan for implementing risk stratification.
  • Select your dataset with care: What makes one resident “high-risk” and another “low-risk” can depend on a number of factors that can be represented in a dataset. When selecting your dataset, instead of focusing on what values to include, look at what values you can exclude. Those that are excluded should not provide much value
  • Have a goal in mind: All long term care facilities should have a goal in mind when implementing risk stratification. For example, maybe a nursing home aims to reduce the number of flu infections. Nursing home administrators should always communicate to their teams the goal they are trying to achieve.
  • Always use first-hand experiences: Nurses and physicians who interact with residents are the best sources of first-hand experience and should never be ignored when employing risk stratification. The best risk stratifications should always incorporate their opinions to create a working system.

The Necessity of Care Coordination Software in Long Term Care EHR

While long term care EHR is a very useful tool for SNFs and nursing homes to store and analyze resident data, it has limitations in coordinating care, especially when an external third party is involved. It is advisable for nursing home administrators to include care coordination software in their long term care EHR in order to facilitate communication between external suppliers and nursing homes. Implementing an efficient long term care software system with built-in care coordination software is the cheapest and easiest option. 

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Elijah Oling Wanga