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Achieving the triple aim of providing better care, lower costs, and improved health, effectively participating in bundled payment programs, successfully transitioning to a fee-for-value reimbursement model—all are key issues long term/post-acute care (LTPAC) providers are grappling with today. And they all have a common key to success: effective care coordination.

Of course care coordination is not a unique concept; it has been standard practice in the acute care world for many years. In an acute care setting, the majority of resources and actors needed to provide care are self-contained. The laboratory, pharmacy, radiology, therapy, dietary, and other resources and corresponding actors are typically in the same physical location. The nurses; therapists; pharmacists; nutritionists; radiologists; and, increasingly, physicians are employees of the hospital entity.

As for engaging family members, the need is fleeting, as sometimes the patient has been discharged before the family even knows the relative was admitted.

Due to the small number of organizational boundaries and the fact that most resources are self-contained within the care setting, interoperability between the various functional systems/modules and electronic care coordination among actors in the care team is largely a closed domain problem.

Accordingly, a few dominant electronic health record (EHR) vendors have emerged by successfully integrating these systems/modules into a full care setting-level medical record, using localized database, application, or message-level (HL-7, proprietary, and so on) integration techniques and then using this consolidated record and user set to drive care coordination activities.

While integrated care certainly remains challenging in the acute care setting, it is an order of magnitude more challenging across the LTPAC spectrum of care. Very few of the resources or care team members are physically co-located or exist under the same organizational boundary, and very few leverage the same information systems.

In skilled nursing-based care settings, nursing and supporting staff likely work for the facility operator and use a facility-centric EHR/tracking system. In home-based care settings, caregivers report to the home care agency and use an agency-centric EHR/tracking system.

Primary care and specialty physicians are almost always independent and use a practice management system to document care. Laboratory and radiology services are outsourced from third parties using specialized systems. Pharmacies are institutional and use specialized pharmacy information systems to manage medications. Therapists and nutritionists are generally from contracted agencies also using specialized care tracking systems.

Also, because the length of stay is longer, the family is much more engaged in the resident’s or patient’s care.

Accordingly, interoperability between the various functional systems/modules and electronic care coordination among members of the care team are largely an open domain problem. The approaches used to address integration and electronic care coordination in the largely closed domain of the acute care setting fall down when applied to the open domain nature of LTPAC.

A different approach is required, one that is patient-centric, where care is coordinated “above the system,” data are exchanged “between the systems” via industry-standard application programming interfaces, and alerts are delivered securely “among the members” based on each care team member’s role in the care process and need and right to know certain information.

Look no further than consumer-grade social media for examples. Applied to the care process, members of the care team can “subscribe” or “follow” a patient or resident and various aspects of her care.

When new information about the patient/resident is “published,” for example, when there is a change in condition, subscribing care team members are securely alerted and prompted for action based on their role and on the device of their choice.

In addition to making information available to a group at large, these platforms often have direct member-to-member messaging capabilities to allow individuals to have private conversations.

Obviously in health care, the model needs to allow for both team and private collaboration, as well as have industrial-strength security to meet the requirements of the Health Information Portability and Accountability Act.

The winning approach to electronic care coordination in LTPAC will leverage a patient-centric, standards-based, publish/subscribe model.

LTPAC EHR vendors that have signed the Interoperability Pledge, announced by Health and Human Services Department Secretary Sylvia Mathews Burwell at the Healthcare Information and Management Systems Society annual meeting this spring, are committed to supporting this winning approach to care coordination, and LTPAC providers can look forward to exciting innovations from them in the coming months and years.