What does coordinated care look like? Donald Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement Sometimes things go well, and that’s because the various influences come together in a kind of rhythm or music that works. I’ll tell you a story. On a different day in my clinical practice, I was called into a room to see a four-year-old boy that I had never met. He had asthma, and he was very tight. He was wheezing a lot. His mother was a very young mother. I’m sure she’d borne him as a young teenager. And I walked into the room, and there was this young woman and her son, and I was worried because he was breathing so hard. But then the process started. As I walked into the room, the mother handed me a chart that she’d kept at home. She had at home a spirometer, a breathing machine, which allowed her to measure her child’s rate of wheezing. And she’d kept this chart and annotated it with various medications that she’d given him at home. She had been taught to do that by a visiting nurse that had been assigned to visit her home, who also had arranged for her to have the test machine at home, and had trained her to use it. She said that she had tried the medicine. She knew what each of them was and she recommended a fourth medicine that she didn’t have at home. She said, “I think maybe he’ll respond to this.” I was not saying very much, because she had the ball and seemed to know what she was doing. But before I could open my mouth to respond, there was a knock on the door. I opened the door, and there standing at the door was the chief of allergy holding a bottle of the medicine that the mother had just mentioned. How did he know to come? Because the mother had the cell phone number of the nurse who’s responsible for coordinating the care and had the called nurse. She had called our allergist, and the allergist brought the medicine down. I was feeling pretty irrelevant. We put the medicine into the nebulizer machine. He cleared immediately, and within an hour was on his way home, instead of to the emergency room, which in any other context, I would have sent him to. He didn’t go home alone. He went home with his mother but also the nurse, who had called the allergist and organized her trip to see me. She was on the way to the kid’s house to check him at home, as she would for the rest of the next few days. That was a child that went home and well instead of to an emergency room, frightened and at very high cost. What happened? Music. A system that reached back into months before, preparing this young mother to have the sense of mastery, to be able to know different things to try with her child; technology that she knew how to use to measure his breathing; and knowledge of improvement. She was doing PDSA [plan-do-study-act] cycles at home as she tried each medicine and annotated the run chart. The communication system linked the mother and the nurse and the allergist and me in a single system so that there was literally no delay at all between his arrival to see me and the arrival of the medicine that was the next one to try. When the system works, that’s what it looks like, full of knowledge about the subject matter of that asthma treatment, full of knowledge about how to try things as she had tried the different medicines at home and studied their effect, full of consciousness of interdependency, a team at work in communication with each other with their egos set aside, all focused on the needs of the individual child. That’s what systems work looks like, and it gets a kid home in bed and not in a hospital.