September 26, 2023

Leveraging Interactive Care Coordination Training to Reduce Avoidable Hospitalizations

Organizations implementing care coordination and care management programming need staff to build strong relationships with their patients, engage them in their care, and navigate across a multitude of needed services. In 2023, the District of Columbia Primary Care Association (DCPCA) partnered with Primary Care Development Corporation (PCDC) to strengthen coordination and care management services among member Federally Qualified Health Centers (FQHCs) to mitigate patient risk, improve outcomes and reduce avoidable hospitalizations. This initiative was intended to support success in the DC Connected Care Network, a value-based care-focused clinically integrated network of local FQHCs. The goal of the Network is to establish value-based care contracts with local Medicaid-managed care organizations. The Clinically Integrated Network has nearly 60,000 Medicaid-attributed beneficiaries among DCPCA’s participating FQHCs.

PCDC worked closely with DCPCA to develop a tailored training experience that included in-person and virtual sessions to strengthen care coordination activities at all participating organizations, regardless of their starting point. Training content was geared toward care coordinator and care manager staff at participating practices. Specifically, PCDC provided training on social determinants of health impact on patient outcomes, health equity, risk stratification, and distributing care management responsibilities across all available health center staff. The culminating in-person session incorporated the development of health center-specific workflows to document care coordination processes.

Ultimately, the training enabled DC health centers to increase their understanding of best practices in care management and care coordination and strengthen their internal care coordination programs. This training was well received, with members noting appreciation of the tools and resources made available, as well as the real-life examples and clear explanations of care management definitions and processes. 86% of attendees across the four sessions reported that they could implement the skills learned from the training. Additionally, all ten FQHCs that attended the training were provided with a health center-specific process map outlining a care coordination process within their organization.

“Thanks to this care coordination training, our FQHC members feel more comfortable addressing the specific needs of their patients and working to prevent costly hospitalizations. The combination of individual skill building, and process mappings ensures that this work can be sustained, and additional patients can be served,” said Tamara Smith, CEO of DCPCA.

“This partnership shows how vital care coordination is to improve patient care and short and long-term health outcomes,” said Maia Morse, MPH, CPC, Director at PCDC.