Care Coordination Deep Dive: What Authority Actually Means

Objective and Context

This study explores what adult children concretely require from a care coordination service: the practical meaning of authority, trust prerequisites, trigger moments for purchase, table stakes vs differentiators, and deal breakers. Across seven questions, respondents consistently defined a results‑oriented “fixer” model with legally backed authority, tight guardrails, and auditable execution-activated at acute moments (ER/discharge, medication blocks, denials) and maintained through low‑noise, human‑led communication.

What “Authority” Actually Means

• Do, not remind: Book/reschedule/cancel across specialists; secure imaging/labs; obtain same‑day urgent visits (e.g., Vanessa May).
• Payer muscle: Submit/chase prior auths; file appeals; schedule peer‑to‑peer; pursue single‑case agreements; fight balance bills (Martha Machuca).
• Medication end‑to‑end: Refills, transfers, formulary swaps, step therapy, blister packs/mail order; obtain PA for costly meds (Shena Bagley).
• Financial authority with guardrails: Demand itemized bills, apply for assistance, set payment plans, and pay approved bills from a dedicated, capped account (Joseph Akin).
• Hospital‑to‑home and in‑home: Attend rounds/ER, coordinate safe discharge, arrange DME/home health/transport; supervise aides; install equipment.
• Escalation ladder: Up to practice managers, insurers, and regulators; 24/7 reachability for crises.
• Prerequisites and red lines: HIPAA, limited medical/financial POA, insurer/pharmacy rep forms; portal/proxy access; audit trails and spend caps; no consent to major surgeries/chemo/EOL changes without family sign‑off.

Trust Requirements

• Verification: FBI fingerprint + state criminal checks; OIG/SAM screens; annual re‑checks (Joseph Monaco).
• Credentials: RN, LCSW, CCM or BCPA for navigation; bonded/insured if touching funds (Martha Machuca).
• Coverage and guarantees: E&O/professional liability (7‑figure aggregate cited), cyber liability, fidelity bond; conflict‑of‑interest transparency.
• Operational limits: Limited POA, per‑transaction/monthly caps, two‑signature rule, segregated client funds (Linda Sauceda).
• Technical control: MFA, role‑based access, immutable audit logs, client‑controlled revocation/kill‑switch (Loretta Uzzell).
• Human factors: In‑person introduction/local presence, named backup, references, staged pilot with SLAs, plain‑English contracts, transparent pricing, easy exit/data return.

Trigger Moments and Conversion

• Acute events: ER visits, discharges, falls; Friday/holiday discharges with hour‑level decisions (Martha Machuca).
• Medication emergencies: Life‑critical refills blocked by prior auth, especially before weekends (Joseph Monaco).
• Financial/legal clocks: Denials with 10–14 day appeal windows; unexpected $800–$2,000 balances.
• Logistics failures: DME/home‑health/transport no‑shows that render discharge unsafe.
• Capacity threshold: ≥6 admin hours/week or a second acute event within 30–90 days. Buyers expect same‑day start, month‑to‑month terms, and proof‑of‑value by solving one hard task in 24–72 hours.

Table Stakes vs Differentiators

• Table stakes: Real authority (HIPAA/POA + portal proxy), payer/PA/appeals competence (including peer‑to‑peer), end‑to‑end meds with pharmacist oversight, discharge‑to‑home and bedside presence, named coordinator + backup with true after‑hours coverage, airtight security/compliance, reliable DME/transport, transparent contracts with audit trails.
• Differentiators: SLA‑backed speed and service credits; deep local/hospital/payer relationships; boots‑on‑the‑ground for high‑risk transitions; RN/LCSW/PharmD‑led teams; proactive prevention (med sync, auth renewals); visible financial guardrails/savings; short pilots; cultural/language concordance; on‑site notarization; explicit no‑resale/no “de‑identified research.”

Deal Breakers and Failure Modes

• One‑strike issues: Privacy/security breaches or offshoring without consent; unauthorized spending or opaque billing; fabricated work/no audit trail; med safety lapses (wrong dose/duplicate therapy) or missed refills beyond 24 hours; missed hard clocks (appeals, prior auths) causing loss of coverage.
• Context risks: Rural/weather blind spots (e.g., frozen meds), failure to honor paper‑first instructions; respondents expect remediation proof within 24–48 hours.

Persona Nuances

• Older/rural: Phone/text first, paper options, in‑person support, weather/logistics aware; keys and home presence matter.
• Health‑system pros: Enterprise controls (SOC2/HITRUST posture), audited logs, SLAs/metrics before scale.
• Mid‑career, higher‑income: Pay premiums for speed, named accountability, outcome‑based pilots.
• Cultural/linguistic: Interpreter access and faith‑aligned EOL handling are trust accelerants and purchase drivers.

Recommendations, Next Steps, and Measurement

• Ship now: Authority Pack with limited POA/spend caps; publish a Trust Center (licenses, FBI/OIG checks, E&O/cyber/fidelity); launch an Emergency Start 72‑hour SKU; implement one‑number routing + weekly digest with event‑driven SMS; stand up top‑5 payer playbooks.
• Build in 90 days: RN/LCSW/BCPA team with 24/7 rota; PharmD med safety; client‑controlled credentials and segregated funds; centralized appeals factory; local pilots (e.g., Kaiser/South Bay + rural) with Spanish language access and episode‑based pricing with fee credits.
• KPIs: Emergency‑Start conversion ≥40%; prior‑auth turnaround ≤48 hours; appeal overturn rate ≥45%; 7‑day post‑discharge scheduling ≥90%; medication lapse incidents ≤1/100 clients/month. Monitor SLA adherence (≤60 minutes urgent, ≤2 business hours routine) and churn reasons tied to deal‑breakers.
• Risk controls: US data residency or explicit offshore consent; immutable audit logs; weekend coverage for 72‑hour clocks; redundant DME/transport vendors and weather playbooks.