The Need for Seamless, Coordinated Care

One of the major challenges facing the U.S. health care system is its high degree of fragmentation. Nowhere is this fragmentation more evident than in the transitions patients must undergo among multiple providers or different services for a single health problem. When care is seamless, these multiple aspects of care are coordinated to enhance the quality of care and the patient’s experience of care. The ACA contains provisions that address coordination of care, but these initiatives are just the beginning of what is needed.

How Seamless, Coordinated Care Improves Quality, Access, and Value

In 2003, the IOM singled out coordination of care as indispensible to improving the quality of health care in the United States (IOM, 2003a). Likewise, the ACA highlights coordination of services as one of the required measures for reporting on the quality of care. The Medicare Payment Advisory Commission (MedPAC) also concluded that better coordination clearly improved the quality of beneficiaries’ care. Proof that care coordination saves money was less apparent in part because measuring cost savings is so difficult. Investments in care coordination for a group of people with diabetes, for example, may take a long time to demonstrate cost savings because it can take years for poor glucose control to manifest itself as stroke, myocardial infarction, and other severe complications. However, the value of preventing these outcomes, from both a quality-of-life and financial perspective, is clear.

One particularly compelling example of the multiple benefits of seamless care is the On Lok program—an initiative that began in California in the 1970s (On Lok PACEpartners, 2006). Its successes inspired a new model of care—the Program of All-Inclusive Care for the Elderly (PACE), which now serves 19,000 frail older individuals in 31 states.2 On Lok and the PACE programs that it inspired demonstrate that innovative programs that integrate care across the continuum can lead to synergistic improvements in quality, access, and value. The creativity and willingness to look beyond traditional solutions that animate these programs need to be adapted to other health care settings.

Nurses and Seamless, Coordinated Care

Coordinating care is one of the traditional strengths of the nursing profession, whether in the community or the acute care setting. For example, an interprofessional research team funded by the Robert Wood Johnson Foundation, called the Interdisciplinary Nursing Quality Research Initiative (INQRI), developed a Staff

2

Personal communication, Shawn Bloom, President and CEO, National PACE Association, February 3, 2010.



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