In the Field: The Challenges of Field Care Delivery
Bridging the Gaps in Patient Care
Ideal healthcare delivery is often described as the right care, at the right place, at the right time, and by the right provider. However, the reality is far from this ideal. Gaps in care coordination, outdated processes, and inefficiencies in field-based healthcare often result in suboptimal patient outcomes and financial strain on the healthcare system.
Nearly one in five seniors are readmitted to the hospital within 30 days of discharge, and this rate doubles to 40% for cardiovascular patients who face transportation or scheduling barriers. While care managers are tasked with reducing readmissions and improving patient outcomes, they spend countless hours on unnecessary driving, manual administrative tasks, and fragmented workflows. These inefficiencies delay or even prevent critical care interventions that could improve patient health and reduce hospital readmissions.
The Impact of Inefficient Transitions of Care (TOC)
The Centers for Medicare & Medicaid Services (CMS) estimates that up to 75% of hospital readmissions are preventable. However, current Transitions of Care (TOC) solutions rely heavily on telephonic or in-office follow-ups, which fail to meet the needs of high-risk populations. Many patients struggle with these traditional approaches due to:
Unanswered phone calls from unknown numbers.
Hearing impairments that make phone assessments challenging.
Limited connectivity in rural areas, restricting telehealth effectiveness.
Mobility issues, transportation barriers, and severe symptoms that make office visits difficult.
As a result, many patients fall through the cracks. Alarmingly, 74% of seniors take their medication incorrectly within seven days of discharge, yet most do not receive a timely medication reconciliation to address this issue. Without proactive interventions, these patients face heightened risks of complications, readmissions, and declining health.
The Struggles of Chronic Care Management (CCM) and Field Care Delivery
Many insurers and providers offer Chronic Care Management (CCM) services for patients with multiple chronic conditions, along with TOC programs for 30 days post-discharge. However, managing TOC effectively is more challenging due to shorter compliance windows and higher patient acuity levels. While some insurers provide in-home services, they lack the necessary automation and digital tools for field teams to work efficiently. The result? Missed opportunities to prevent readmissions, wasted resources, and declining performance in key healthcare quality metrics, such as:
Health Effectiveness Data Set (HEDIS)
Merit-Based Incentive Program (MIPS)
Hospital Readmission Reduction Program (HRRP)
National Committee for Quality Assurance (NCQA)
The Growing Demand for Field-Based Healthcare Services
The need for home-based healthcare solutions is rapidly increasing due to several key demographic and industry shifts:
By 2030, one in five Americans will be over 65, leading to an increased demand for in-home chronic care and aging-in-place solutions.
More than 60% of U.S. adults live with at least one chronic disease, many of whom require frequent monitoring and in-home interventions.
The transition toward value-based care models is driving a push to reduce hospitalizations and unnecessary emergency room visits, making field care delivery a critical component of cost-effective healthcare.
Despite this growing need, the field care workforce is overburdened, reimbursement models remain outdated, and care teams lack the technology necessary to provide efficient, high-quality care in the field.
The Cost of Inaction: A Looming Healthcare Crisis
If field care delivery does not evolve, the healthcare system will face dire consequences, including:
Increased hospital overcrowding due to preventable readmissions and worsening chronic conditions.
Expanding care deserts, leaving rural and underserved populations without access to basic healthcare services.
More costly and less dignified end-of-life care, with more patients forced into hospital settings instead of receiving appropriate in-home support.
Skyrocketing healthcare spending, which is already projected to reach nearly $6.2 trillion by 2028, exacerbated by avoidable hospitalizations and inefficient care pathways.
Investing in field care delivery isn’t just about improving patient experiences—it’s an economic necessity. Keeping people healthier at home reduces preventable hospitalizations, emergency room visits, and long-term facility stays, leading to significant cost savings and improved quality of life.
The Path Forward: A Technology-Enabled Approach to Field Care
To unlock the full potential of field-based healthcare, we must modernize how care teams operate. The future of field care delivery depends on empowering clinicians with:
Real-time access to patient data to make informed decisions at the point of care.
Seamless provider coordination to ensure smooth transitions between hospitals, homes, and community-based services.
Automated administrative processes that reduce paperwork and free up time for direct patient care.
Intelligent scheduling and workforce optimization to ensure that care is delivered efficiently and effectively.
At Coordinista, we are building the infrastructure to help field care teams thrive. By streamlining workflows, improving care coordination, and leveraging smart automation, we empower healthcare organizations to enhance efficiency, reduce waste, and provide high-quality care where it matters most—in the field.
Field Care Delivery: A Necessity, Not an Option
The demand for effective field care delivery is only growing. With rising patient needs and shifting healthcare priorities, organizations must invest in innovative solutions that support clinicians, enhance patient outcomes, and optimize resources. By prioritizing field-based healthcare, we can build a system that is more efficient, cost-effective, and ultimately, better for patients.
The time for action is now. The future of healthcare depends on our ability to meet patients where they are—delivering the right care, at the right place, at the right time.