A multidimensional home-based care coordination intervention for elders with memory disorders: the maximizing independence at home (MIND) pilot randomized trial

OBJECTIVES

To assess whether a dementia care coordination intervention delays time to transition from home and reduces unmet needs in elders with memory disorders.

DESIGN

18-month randomized controlled trial of 303 community-living elders.

SETTING

28 postal code areas of Baltimore, MD.

PARTICIPANTS

Age 70+ years, with a cognitive disorder, community-living, English-speaking, and having a study partner available.

INTERVENTION

18-month care coordination intervention to systematically identify and address dementia-related care needs through individualized care planning; referral and linkage to services; provision of dementia education and skill-building strategies; and care monitoring by an interdisciplinary team.

MEASUREMENTS

Primary outcomes were time to transfer from home and total percent of unmet care needs at 18 months.

RESULTS

Intervention participants had a significant delay in time to all-cause transition from home and the adjusted hazard of leaving the home was decreased by 37% (Hazard ratio: 0.63, 95% Confidence Interval: 0.42-0.94) compared with control participants. Although there was no significant group difference in reduction of total percent of unmet needs from baseline to 18 months, the intervention group had significant reductions in the proportion of unmet needs in safety and legal/advance care domains relative to controls. Intervention participants had a significant improvement in self-reported quality of life (QOL) relative to control participants. No group differences were found in proxy-rated QOL, neuropsychiatric symptoms, or depression.

CONCLUSIONS

A home-based dementia care coordination intervention delivered by non-clinical community workers trained and overseen by geriatric clinicians led to delays in transition from home, reduced unmet needs, and improved self-reported QOL.

Effectiveness of a national transitional care program in reducing acute care use

This study evaluated the effectiveness of a national transitional care program for elderly adults with complex care needs and limited social support. The Aged Care Transition (ACTION) Program was designed to improve coordination and continuity of care and reduce rehospitalizations and visits to emergency departments (EDs). Dedicated care coordinators provided coaching to help individuals and families understand the individuals' conditions, effectively articulate their preferences, and enable self-management and care planning. Participants were individuals aged 65 and older hospitalized and enrolled from five public general hospitals in Singapore between February 2009 and July 2010 (N = 4,132). The coordinators worked with participants during hospitalization and followed up with telephone calls and home visits for 1 to 2 months after discharge and coordinated placements with appropriate community service providers. Unplanned rehospitalization and ED visit (up to 6 months after discharge) rates were compared with those of a comparator group of individuals who did not receive care coordination using propensity score-based weighting. Participant and caregiver surveys on quality of life and self-rated health were also administered. Recipients of the ACTION program had fewer unplanned rehospitalizations and ED visits after discharge. Propensity score-adjusted odds ratios of participants versus control for number of unplanned rehospitalization and ED visits were 0.5 (95% confidence interval (CI) = 0.5-0.6) and 0.81 (95% CI = 0.72-0.90) 30 days after discharge and 0.6 (95% CI = 0.6-0.7) and 0.90 (95% CI = 0.82-0.99) 180 days after discharge. Quality of life and self-rated health were better 4 to 6 weeks after discharge than 1 week after discharge. These findings confirm the effectiveness of the ACTION program in improving the transition of vulnerable older adults from hospital to community. Such transitional care should be considered as an integral part of care integration.

Need and unmet need for care coordination among children with mental health conditions

OBJECTIVE

To determine prevalence and correlates of need and unmet need for care coordination in a national sample of children with mental health conditions.

METHODS

Using data from the 2007 National Survey of Children's Health, we identified children aged 2 to 17 years with ≥1 mental health condition (attention-deficit/hyperactivity disorder, anxiety disorder, conduct disorder, or depression) who had received ≥2 types of preventive or subspecialty health services in the past year. We defined 2 outcome measures of interest: (1) prevalence of need for care coordination; and (2) prevalence of unmet need for care coordination in those with a need. Logistic regression models were used to estimate associations of clinical, sociodemographic, parent psychosocial, and health care characteristics with the outcome measures.

RESULTS

In our sample (N = 7501, representing an estimated 5,750,000 children), the prevalence of having any need for care coordination was 43.2%. Among parents reporting a need for care coordination, the prevalence of unmet need was 41.2%. Higher risk of unmet need for care coordination was associated with child anxiety disorder, parenting stress, lower income, and public or no insurance. Parents reporting social support and receipt of family-centered care had a lower risk of unmet need for care coordination.

CONCLUSIONS

Approximately 40% of parents of children with mental health conditions who reported a need for care coordination also reported that their need was unmet. Delivery of family-centered care and enhancing family supports may help to reduce unmet need for care coordination in this vulnerable population.

Integrated community-healthcare diabetes interventions to reduce disparities

Racial and ethnic minorities suffer disproportionately from diabetes-related morbidity and mortality. With the creation of Accountable Care Organizations (ACOs) under the Affordable Care Act, healthcare organizations may have an increased motivation to implement interventions that collaborate with community resources and organizations. As a result, there will be an increasing need for evidence-based strategies that integrate healthcare and community components to reduce diabetes disparities. This paper summarizes the types of community/health system partnerships that have been implemented over the past several years to improve minority health and reduce disparities among racial/ethnic minorities and describes the components that are most commonly integrated. In addition, we provide our recommendations for creating stronger healthcare and community partnerships through enhanced community support.

Cost-effective: emergency department care coordination with a regional hospital information system

BACKGROUND

Frequent and unnecessary utilization of the emergency department (ED) is often a sign of serious latent patient issues, and the associated costs are shared by many. Helping these patients get the care they need in the appropriate setting is difficult given their complexity, and their tendency to visit multiple EDs.

STUDY OBJECTIVE

We analyzed the cost-effectiveness of a multidisciplinary ED-care-coordination program with a regional hospital information system capable of sharing patients' individualized care plans with cooperating EDs.

METHODS

ED visits, treatment costs, cost per visit, and net income were assessed pre- and postenrollment in the program using nonparametric bootstrapping techniques. Individuals were categorized as frequent (3-11 ED visits in the 365 days preceding enrollment) or extreme (≥12 ED visits) users. Regression to the mean was tested using an adjusted measure of change.

RESULTS

Both frequent and extreme users experienced significant decreases in ED visits (5 and 15, respectively; 95% confidence intervals [CI] 2-5 and 13-17, respectively) and direct-treatment costs ($1285; 95% CI $492-$2364 and $6091; 95% CI $4298-$8998, respectively), leading to significant hospital cost savings and increased net income ($431; 95% CI $112-$878 and $1925; 95% CI $1093-$3159, respectively). The results further indicate that fewer resources were utilized per visit. Regression to the mean did not seem to be an issue.

CONCLUSIONS

When examined as a whole, research on the program suggests that expanding it would be an efficient allocation of hospital, and possibly societal, resources.

Implementing community-based diabetes programs: the scripps whittier diabetes institute experience

Diabetes affects a large and growing segment of the US population. Ethnic and racial minorities are at disproportionate risk for diabetes, with Hispanics and non-Hispanic Blacks showing a near doubling of risk relative to non-Hispanic Whites. There is an urgent need to identify low cost, effective, and easily implementable primary and secondary prevention approaches, as well as tertiary strategies that delay disease progression, complications, and associated deterioration in function in patients with diabetes. The Chronic Care Model provides a well-accepted framework for improving diabetes and chronic disease care in the community and primary care medical home. A number of community-based diabetes programs have incorporated this model into their infrastructure. Diabetes programs must offer accessible information and support throughout the community and must be delivered in a format that is understood, regardless of literacy and socioeconomic status. This article will discuss several successful, culturally competent community-based programs and the key elements needed to implement the programs at a community or health system level. Health systems together with local communities can integrate the elements of community-based programs that are effective across the continuum of the care to enhance patient-centered outcomes, enable patient acceptability and ultimately lead to improved patient engagement and satisfaction.

Improving outcomes for underserved adolescents with asthma

BACKGROUND AND OBJECTIVE

Asthma is the most common chronic disease of childhood. Treatment adherence by adolescents is often poor, and their outcomes are worse than those of younger patients. We conducted a quality improvement initiative to improve asthma control and outcomes for high-risk adolescents treated in a primary care setting.

METHODS

Interventions were guided by the Chronic Care Model and focused on standardized and evidence-based care, care coordination and active outreach, self-management support, and community connections.

RESULTS

Patients with optimally well-controlled asthma increased from ∼10% to 30%. Patients receiving the evidence-based care bundle (condition/severity characterized in chart and, for patients with persistent asthma, an action plan and controller medications at the most recent visit) increased from 38% to at or near 100%. Patients receiving the required self-management bundle (patient self-assessment, stage-of-readiness tool, and personal action plan) increased from 0% to ∼90%. Patients and parents who were confident in their ability to manage their or their adolescent's asthma increased from 70% to ∼85%. Patient satisfaction and the mean proportion of patients with asthma-related emergency department visits or hospitalizations remained stable at desirable levels.

CONCLUSIONS

Implementing interventions focused on standardized and evidence-based care, self-management support, care coordination and active outreach, linkage to community resources, and enhanced follow-up for patients with chronically not-well-controlled asthma resulted in sustained improvement in asthma control in adolescent patients. Additional interventions are likely needed for patients with chronically poor asthma control.

Identifying indicators of colorectal cancer care coordination: a Delphi study

AIM

Care coordination is an important aspect of the quality of cancer care but is difficult to evaluate due to the lack of valid and reliable measures. This study was conducted to identify a set of objective measures of colorectal cancer care coordination that could be included in a medical record audit tool.

METHOD

A two-stage Delphi study was conducted to gain consensus among a national panel of experts about the validity of 41 potential indicators of colorectal cancer care coordination that had been identified during a literature review. The expert panel comprised 20 members from the National Health and Medical Research Colorectal Cancer Guidelines Working Party plus representatives from cancer nursing/coordination, general practice and cancer consumers.

RESULTS

Consensus was reached on the validity of 15 of 41 potential indicators, including those that focused on practical aspects of communication (legibility, clarity, content and timeliness of hospital discharge letters, documentation of outcomes of multidisciplinary team meetings) and appropriateness (documentation of preoperative consultation with a stoma therapist, discussions and referrals for adjuvant therapy for appropriate patients, and treatment by an experienced colorectal surgeon). There was lack of consensus on the validity of indicators relating to access to and efficiency of services.

CONCLUSION

The study has identified a core set of measures considered to be valid indicators of colorectal cancer care coordination. A medical record audit based on these measures could be used to monitor adequacy of cancer care coordination and will complement subjective measures based on self-reported experiences of patients and carers.

Measuring primary care organizational capacity for diabetes care coordination: the Diabetes Care Coordination Readiness Assessment

BACKGROUND

Not all primary care clinics are prepared to implement care coordination services for chronic conditions, such as diabetes. Understanding true capacity to coordinate care is an important first-step toward establishing effective and efficient care coordination. Yet, we could identify no diabetes-specific instruments to systematically assess readiness and/or status of primary care clinics to engage in diabetes care coordination.

OBJECTIVE

This report describes the development and initial validation of the Diabetes Care Coordination Readiness Assessment (DCCRA), which is intended to measure primary care clinic readiness to coordinate care for adult patients with diabetes.

DESIGN

The instrument was developed through iterative item generation within a framework of five domains of care coordination: Organizational Capacity, Care Coordination, Clinical Management, Quality Improvement, and Technical Infrastructure.

PARTICIPANTS

Validation data was collected on 39 primary care clinics.

MAIN MEASURES

Content validity, inter-rater reliability, internal consistency, and construct validity of the 49-item instrument were assessed.

KEY RESULTS

Inter-rater agreement indices per item ranged from 0.50 to 1.0. Cronbach's alpha of the entire instrument was 0.964, and for the five domain scales ranged from 0.688 to 0.961. Clinics with existing care coordinators were rated as more ready to support care coordination than clinics without care coordinators for the entire DCCRA and for each domain, supporting construct validity.

CONCLUSIONS

As providers increasingly attempt to adopt patient-centered approaches, introduction of the DCCRA is timely and appropriate for assisting clinics with identifying gaps in provision of care coordination services. The DCCRA's strengths include promising psychometric properties. A valid measure of diabetes care coordination readiness should be useful in diabetes program evaluation, assistance with quality improvement initiatives, and measurement of patient-centered care in research.

The association between EHRs and care coordination varies by team cohesion

OBJECTIVE

To examine whether primary care team cohesion changes the association between using an integrated outpatient-inpatient electronic health record (EHR) and clinician-rated care coordination across delivery sites.

STUDY DESIGN

Self-administered surveys of primary care clinicians in a large integrated delivery system, collected in 2005 (N=565), 2006 (N=678), and 2008 (N=626) during the staggered implementation of an integrated EHR (2005-2010), including validated questions on team cohesion. Using multivariable regression, we examined the combined effect of EHR use and team cohesion on three dimensions of care coordination across delivery sites: access to timely and complete information, treatment agreement, and responsibility agreement.

PRINCIPAL FINDINGS

Among clinicians working in teams with higher cohesion, EHR use was associated with significant improvements in reported access to timely and complete information (53.5 percent with EHR vs. 37.6 percent without integrated-EHR), agreement on treatment goals (64.3 percent vs. 50.6 percent), and agreement on responsibilities (63.9 percent vs. 55.2 percent, all p<.05). We found no statistically significant association between use of the integrated-EHR and reported care coordination in less cohesive teams.

CONCLUSION

The association between EHR use and reported care coordination varied by level of team cohesion. EHRs may not improve care coordination in less cohesive teams.

The University of California at Los Angeles Alzheimer's and Dementia Care program for comprehensive, coordinated, patient-centered care: preliminary data

Dementia is a chronic disease that requires medical and social services to provide high-quality care and prevent complications. As a result of time constraints in practice, lack of systems-based approaches, and poor integration of community-based organizations (CBOs), the quality of care for dementia is poorer than that for other diseases that affect older persons. The University of California at Los Angeles (UCLA) Alzheimer's and Dementia Care (UCLA ADC) program partners with CBOs to provide comprehensive, coordinated, patient-centered care for individuals with Alzheimer's disease and other dementias. The goals of the program are to maximize function, independence, and dignity; minimize caregiver strain and burnout; and reduce unnecessary costs. The UCLA ADC program consists of five core components: recruitment and a dementia registry, structured needs assessments of individuals in the registry and their caregivers, creation and implementation of individualized dementia care plans based on needs assessments and input from the primary care physicians, monitoring and revising care plans as needed, and around-the-clock access for assistance and advice. The program uses a comanagement model with a nurse practitioner Dementia Care Manager working with primary care physicians and CBOs. Based on the first 150 individuals served, the most common recommendations in the initial care plans were referrals to support groups (73%) and Alzheimer's Association Safe Return (73%), caregiver training (45%), and medication adjustment (41%). The program will be evaluated on its ability to achieve the triple aim of better care for individuals, better health for populations, and lower costs.

Health care needs of children with Tourette syndrome

To document the impact of Tourette syndrome on the health care needs of children and access to health care among youth with Tourette syndrome, parent-reported data from the 2007-2008 National Survey of Children's Health were analyzed. Children with Tourette syndrome had more co-occurring mental disorders than children with asthma or children without Tourette syndrome or asthma and had health care needs that were equal to or greater than children with asthma (no Tourette syndrome) or children with neither asthma nor Tourette syndrome. Health care needs were greatest among children with Tourette syndrome and co-occurring mental disorders, and these children were least likely to receive effective care coordination. Addressing co-occurring conditions may improve the health and well-being of children with Tourette syndrome. Strategies such as integration of behavioral health and primary care may be needed to improve care coordination.

The current capabilities of health information technology to support care transitions

To determine whether HIT currently supports care transitions we interviewed clinicians from several healthcare settings. We learned about HIT tools to help nurses facilitate transitions, but discovered that there are few tools to promote high quality, safe transitions of care. We also found that HIT is rarely employed for patient-centered care coordination mechanisms. In conclusion, HIT tools are typically used within one healthcare setting to prepare for a transition, rather than across healthcare settings.

The Impact of an Infectious Diseases Transition Service on the Care of Outpatients on Parenteral Antimicrobial Therapy

BACKGROUND

Many hospitalized patients with complicated infections are discharged on outpatient parenteral antimicrobial therapy (OPAT). However, little is known about how to improve the postdischarge care of OPAT patients.

OBJECTIVE

The impact of an infectious diseases transitions service (IDTS) on OPAT patient readmissions, as well as on processes of care, was evaluated.

METHODS

We performed a controlled, quasi-experimental evaluation over 15 months in an academic medical center. Intervention-arm patients, before and after the introduction of an IDTS, were seen by the general infectious diseases consult teams, while control-arm patients (discharged on OPAT after hospitalization with bacteremia) were not. The IDTS prospectively tracked all OPAT patients and coordinated follow-up. The impact of the IDTS was calculated using a differences-in-differences approach where the interaction between time (before vs after the IDTS intervention) and study arm (intervention vs control arm) was the variable of interest. The control arm was used only in primary outcome analyses (readmissions and emergency department visits). Secondary outcomes included process of care measures and non-readmission clinical outcomes.

RESULTS

Of 488 consecutive patients requiring OPAT, 362 were in the intervention arm (215 pre-intervention and 147 post-intervention) and 126 in the control arm (70 pre-intervention and 56 post-intervention). Compared to the control arm, the IDTS was not associated with changes in 60-day readmissions and/or emergency department visits (adjusted odds ratio [OR] = 0.48; 95% confidence interval [CI] = 0.13-1.79). In the intervention arm, implementation of the IDTS was associated with fewer antimicrobial therapy errors (OR = 0.062; 95% CI = 0.015-0.262), increased laboratory test receipt (OR = 27.85; 95% CI = 12.93-59.99), and improved outpatient follow-up (OR = 2.44; 95% CI = 1.50-3.97).

CONCLUSIONS

In a controlled evaluation, the IDTS did not affect readmissions despite improving process of care measures for targeted patients. Care coordination services may improve OPAT quality of care, but their relationship to readmissions is unclear.

High-value transitional care: translation of research into practice

OBJECTIVE

To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence-based approach to address the needs of chronically ill older adults throughout acute episodes of illness.

METHODS

A prospective, quasi-experimental study of 172 at-risk Aetna Medicare Advantage members in the mid-Atlantic region who received the TCM. A baseline and post-intervention (average of 2 months) comparison of enrolees' health status and quality of life was conducted. Member and physician satisfaction were assessed within 1 month post intervention. Health resource utilization and cost outcomes were compared to a matched control group of Aetna members at multiple intervals through 1 year.

RESULTS

Improvements in all health status and quality of life measures were observed post- intervention compared to pre-intervention. Among 155 stringently matched pairs, a significant decrease in number of re-hospitalizations (45 vs. 60, P < 0.041) and total hospital days (252 vs. 351, P < 0.032) were observed at 3 months. Reductions in other utilization outcomes or time points were not statistically significant. The TCM was associated with a short-term decrease of $439 per member per month in total health care costs at 3 months and cumulative per member savings of $2170 at 1 year (P < 0.037).

CONCLUSIONS

Findings demonstrate that a rigorously tested model of transitional care for chronically ill older adults can be successfully translated into a real-world organization and achieve higher value.

Macroergonomics in Healthcare Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.

Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations

BACKGROUND

As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.

OBJECTIVE

We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.

DESIGN

Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year.

PARTICIPANTS

2,853,030 patients from 814 VHA primary care clinics

MAIN MEASURES

Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®.

KEY RESULTS

The overall mean home builder score in the study clinics was 88 (SD = 13) or 69%. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3% (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074).

CONCLUSION

Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.

Caregiver outcomes of partners in dementia care: effect of a care coordination program for veterans with dementia and their family members and friends

The objective is to test the effectiveness of Partners in Dementia Care (PDC), a care-coordination program that integrates and improves access to medical and nonmedical services, while strengthening the informal care network and providing information, coaching, and emotional support. PDC was delivered via a partnership between Veterans Affairs (VA) Medical Centers (VAMCs) and Alzheimer's Association chapters, for caregivers of veterans with dementia living in the community and receiving primary care from the VA. The initial sample was 486 caregivers of 508 veterans with diagnosed dementia. Outcomes were evaluated for 394 and 324 caregivers who completed 6- and 12- month follow-up, respectively. PDC had a standardized protocol that included assessment and reassessment, action planning, and ongoing monitoring. It was delivered by telephone and e-mail for cost efficiency and the ability to handle caseloads of 100 to 125. Care coordinators from VAMCs and Alzheimer's Association chapters worked as a team using a shared computerized record. A variety of caregiver outcomes was measured after 6 and 12 months. Intervention group caregivers had significant improvements in outcomes representing unmet needs, three types of caregiver strains, depression, and two support resources. Most improvements were evident after 6 months, with more-limited improvements from Months 6 to 12. Some outcomes improved for all caregivers, whereas some improved for caregivers experiencing more initial difficulties or caring for veterans with more-severe impairments. PDC is a promising model that improves linkages between healthcare services and community services, which is a goal of several new national initiatives such as the National Plan to Address Alzheimer's Disease and a proposed amendment to the Older Americans Act.

Care coordination for children with complex special health care needs: the value of the advanced practice nurse's enhanced scope of knowledge and practice

Efficiency and effectiveness of care coordination depends on a match between the needs of the population and the skills, scope of practice, and intensity of services provided by the care coordinator. Existing literature that addresses the relevance of the advanced practice nurse (APN) role as a fit for coordination of care for children with special health care needs (SHCN) is limited. The objective of this article is to describe the value of the APN's enhanced scope of knowledge and practice for relationship-based care coordination in health care homes that serve children with complex SHCN. The TeleFamilies project is provided as an example of the integration of an APN care coordinator in a health care home for children with SHCN.

An in-depth analysis of theoretical frameworks for the study of care coordination

Introduction

Complex chronic conditions often require long-term care from various healthcare professionals. Thus, maintaining quality care requires care coordination. Concepts for the study of care coordination require clarification to develop, study and evaluate coordination strategies. In 2007, the Agency for Healthcare Research and Quality defined care coordination and proposed five theoretical frameworks for exploring care coordination. This study aimed to update current theoretical frameworks and clarify key concepts related to care coordination.

Methods

We performed a literature review to update existing theoretical frameworks. An in-depth analysis of these theoretical frameworks was conducted to formulate key concepts related to care coordination.

Results

Our literature review found seven previously unidentified theoretical frameworks for studying care coordination. The in-depth analysis identified fourteen key concepts that the theoretical frameworks addressed. These were ‘external factors’, ‘structure’, ‘tasks characteristics’, ‘cultural factors’, ‘knowledge and technology’, ‘need for coordination’, ‘administrative operational processes’, ‘exchange of information’, ‘goals’, ‘roles’, ‘quality of relationship’, ‘patient outcome’, ‘team outcome’, and ‘(inter)organizational outcome’.

Conclusion

These 14 interrelated key concepts provide a base to develop or choose a framework for studying care coordination. The relational coordination theory and the multi-level framework are interesting as these are the most comprehensive.

Let the left hand know what the right is doing: a vision for care coordination and electronic health records

Despite the potential for electronic health records to help providers coordinate care, the current marketplace has failed to provide adequate solutions. Using a simple framework, we describe a vision of information technology capabilities that could substantially improve four care coordination activities: identifying collaborators, contacting collaborators, collaborating, and monitoring. Collaborators can include any individual clinician, caregiver, or provider organization involved in care for a given patient. This vision can be used to guide the development of care coordination tools and help policymakers track and promote their adoption.

Patient sharing among physicians and costs of care: a network analytic approach to care coordination using claims data

BACKGROUND

Improving care coordination is a national priority and a key focus of health care reforms. However, its measurement and ultimate achievement is challenging.

OBJECTIVE

To test whether patients whose providers frequently share patients with one another-what we term 'care density'-tend to have lower costs of care and likelihood of hospitalization.

DESIGN

Cohort study

PARTICIPANTS

9,596 patients with congestive heart failure (CHF) and 52,688 with diabetes who received care during 2009. Patients were enrolled in five large, private insurance plans across the US covering employer-sponsored and Medicare Advantage enrollees

MAIN MEASURES

Costs of care, rates of hospitalizations

KEY RESULTS

The average total annual health care cost for patients with CHF was $29,456, and $14,921 for those with diabetes. In risk adjusted analyses, patients with the highest tertile of care density, indicating the highest level of overlap among a patient's providers, had lower total costs compared to patients in the lowest tertile ($3,310 lower for CHF and $1,502 lower for diabetes, p < 0.001). Lower inpatient costs and rates of hospitalization were found for patients with CHF and diabetes with the highest care density. Additionally, lower outpatient costs and higher pharmacy costs were found for patients with diabetes with the highest care density.

CONCLUSION

Patients treated by sets of physicians who share high numbers of patients tend to have lower costs. Future work is necessary to validate care density as a tool to evaluate care coordination and track the performance of health care systems.

Stakeholder priorities for comparative effectiveness research in chronic obstructive pulmonary disease: a workshop report

Comparative effectiveness research (CER) is intended to address the expressed needs of patients, clinicians, and other stakeholders. Representatives of 54 stakeholder groups with an interest in chronic obstructive pulmonary disease (COPD) participated in workshops convened by the COPD Outcomes-based Network for Clinical Effectiveness and Research Translation (CONCERT) over a 2-year period. Year 1 focused on chronic care and care coordination. Year 2 focused on acute care and transitions in care between healthcare settings. Discussions and provisional voting were conducted via teleconferences and e-mail exchanges before the workshop. Final prioritization votes occurred after in-person discussions at the workshop. We used a modified Delphi approach to facilitate discussions and consensus building. To more easily quantify preferences and to evaluate the internal consistency of rankings, the Analytic Hierarchy Process was incorporated in Year 2. Results of preworkshop and final workshop voting often differed, suggesting that prioritization efforts relying solely on requests for topics from stakeholder groups without in-person discussion may provide different research priorities. Research priorities varied across stakeholder groups, but generally focused on studies to evaluate different approaches to healthcare delivery (e.g., spirometry for diagnosis and treatment, integrated healthcare strategies during transitions in care) rather than head-to-head comparisons of medications. This research agenda may help to inform groups intending to respond to CER funding opportunities in COPD. The methodologies used, detailed in the online supplement, may also help to inform prioritization efforts for CER in other health conditions.

Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers

Efforts to redesign primary care require multiple supports. Two potential members of the primary care team-practice facilitator and care manager-can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities-reflecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices. Care managers provide direct patient care by coordinating care and helping patients navigate the system, improving access for patients, and communicating across the care team. These complementary roles aim to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.

Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care

INTRODUCTION

Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care.

METHODS

The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework.

RESULTS

The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels.

DISCUSSION

The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective.

Implementing a care coordination program for children with special healthcare needs: partnering with families and providers

Care coordination has been a key theme in national forums on healthcare quality, design, and improvement. This article describes the characteristics of a care coordination program aimed at supporting families in building care coordination competencies and providers in the coordination of care across multiple specialties. The program included implementation of a Care Coordination Counselor (CC Counselor) and several supporting tools-Care Binders, Complex Scheduling, Community Resources for Families Database, and a Care Coordination Network. Patients were referred by a healthcare provider to receive services from the CC Counselor or to receive a Care Binder organizational tool. To assess the impact of the counselor role, we compared patient experience survey results from patients receiving CC Counselor services to those receiving only the Care Binder. Our analysis found that patients supported by the CC Counselor reported greater agreement with accessing care coordination resources and identifying a key point person for coordination. Seventy-five percent of CC Counselor patients have graduated from the program. Our findings suggest that implementation of a CC Counselor role and supporting tools offers an integrative way to connect patients, families, and providers with services and resources to support coordinated, continuous care.

A qualitative analysis of an advanced practice nurse-directed transitional care model intervention

PURPOSE

The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs).

DESIGN AND METHODS

APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences.

RESULTS

Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond.

IMPLICATIONS

APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

Implementation and evaluation of an automated patient death notification policy at a tertiary pediatric oncology referral center

BACKGROUND

Not knowing about a child's death can result in poor quality of care coordination among staff and poor quality bereavement care for families. The purpose of this project was to create, implement, and evaluate an automated Patient Death Notification policy and procedure (PDNPP).

MEASURES

Baseline and follow-up surveys of clinical staff.

INTERVENTION

Implementation of a PDNPP that created an automated, systematic process for staff notification of patient deaths.

OUTCOMES

Ninety-six percent of the staff rated the PDNPP as a significant improvement; 91% reported being "very" or "somewhat" satisfied with the PDNPP, whereas only 44% of the staff were satisfied with the process at baseline.

CONCLUSIONS/LESSONS LEARNED

Implementation of an automated PDNPP was feasible and improved staff satisfaction about how they were informed of patient deaths. Staff also reported being notified about patient deaths more quickly, performing their jobs more efficiently, being able to avoid doing something that might upset the deceased patient's family, and being able to better provide support to bereaved families.

Dual Medicare and Veteran Health Administration use and ambulatory care sensitive hospitalizations

OBJECTIVE

The objective of the study is to examine the association between ambulatory care sensitive hospitalizations (ACSH) and dual Medicare/Veteran Health Administration use.

PARTICIPANTS

A nationally representative sample of Medicare beneficiaries, who participated in the Medicare Current Beneficiary Survey (MCBS).

DESIGN/MEASUREMENTS

Cross-sectional analyses (N = 44,988) of linked fee-for-service Medicare claims and survey data from multiple years of the MCBS (2001-2005). Any ACSH and specific types of ACSH were measured using the list of prevention quality indicators developed by the Agency for Healthcare Research and Quality. Among veterans, dual Medicare/VHA use was defined as having inpatient or outpatient visits paid by VHA and consisted of three categories: 1) predominant-VHA use; 2) some VHA use and no VHA use. Unadjusted group differences in any ACSH were tested using chi-square tests. Logistic regressions were used to analyze the association between dual Medicare/VHA use and ACSH after controlling for demographic, socio-economic status, health status, functional status, smoking status and obesity. All analyses accounted for the complex design of the MCBS.

RESULTS

Among inpatient users, 10.1% had ACSH events for acute conditions and 15.8% for chronic conditions. Among all survey respondents, 5% had any ACSH event. Among predominant-VHA users the rate was 4.9% and among veterans with some VHA use it was 3.7%. In bivariate and multivariate analyses, dual Medicare/VHA use was not significantly associated with any ACSH.

CONCLUSION

In a representative sample of Medicare beneficiaries, despite low income and health status, veterans with dual Medicare/VHA use were as likely as veterans without dual use to have any ACSH, perhaps due to expanded healthcare access and emphasis on primary care in the VHA system.

Patient-reported care coordination: associations with primary care continuity and specialty care use

PURPOSE

Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use.

METHODS

We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use.

RESULTS

Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77).

CONCLUSIONS

High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.

Family presence in routine medical visits: a meta-analytical review

Older adults are commonly accompanied to routine physician visits, primarily by adult children and spouses. This is the first review of studies investigating the dynamics and consequences of patient accompaniment. Two types of evidence were examined: (1) observational studies of audio and/or videotaped medical visits, and (2) surveys of patients, families, or health care providers that ascertained experiences, expectations, and preferences for family companion presence and behaviors in routine medical visits. Meta-analytic techniques were used to summarize the evidence describing attributes of unaccompanied and accompanied patients and their companions, medical visit processes, and patient outcomes. The weighted mean rate of patient accompaniment to routine adult medical visits was 37.6% in 13 contributing studies. Accompanied patients were significantly older and more likely to be female, less educated, and in worse physical and mental health than unaccompanied patients. Companions were on average 63 years of age, predominantly female (79.4%), and spouses (54.7%) or adult children (32.2%) of patients. Accompanied patient visits were significantly longer, but verbal contribution to medical dialog was comparable when accompanied patients and their family companion were compared with unaccompanied patients. When a companion was present, health care providers engaged in more biomedical information giving. Given the diversity of outcomes, pooled estimates could not be calculated: of 5 contributing studies 0 were unfavorable, 3 inconclusive, and 2 favorable for accompanied relative to unaccompanied patients. Study findings suggest potential practical benefits from more systematic recognition and integration of companions in health care delivery processes. We propose a conceptual framework to relate family companion presence and behaviors during physician visits to the quality of interpersonal health care processes, patient self management and health care.

Utilization of legal and financial services of partners in dementia care study

Financial and legal services are unique needs of persons with dementia and their caregivers. This study examines their need for legal and financial assistance and the kinds of legal and financial services provided within Partners in Dementia Care, a telephone-based, care coordination and support service intervention delivered through a partnership between Veterans Affairs (VA) medical centers and local Alzheimer's Association chapters. Based on comprehensive assessment, and needs prioritization, care coordinators collaboratively planned action steps (specific behavioral tasks) with each caregiver/person with dementia to address the dyad's identified unmet needs. Results show that 51 (54.8%) of 93 dyads reported a need for legal and financial services. Action steps related to legal and financial need included education or assistance with legal services (27.27%), nonhealth-related financial benefits (32.32%), health-related financial benefits (21.21%), financial management/planning (9.09%), and financial support (10.1%). Comparable numbers of action steps were directed to VA (41.4%) and non-VA (58.6%) services.

Characteristics of elderly patients receiving care coordination: the role of telephonic review and home visit

Introduction

Aim/objectives

Research design and sampling

Result

Discussion

Conclusion

Benefits and challenges perceived by patients with cancer when offered a nurse navigator; a qualitative study

Purpose

To explore the experiences of patients with cancer who were offered a nurse navigator in their course of illness before the in-hospital period.

Theory

Development has fragmentized healthcare systems in many countries, and coherence is now desired. Among interventions suggested to reduce the fragmentation and improve delivery of care are help from patient navigators, where patients are offered extra help in a defined area by e.g., a nurse [nurse navigator (NN)]. Patients’ experiences are of major interest, but have seldom been thoroughly investigated.

Methods

A phenomenological-hermeneutical longitudinal study was performed among Danish gynecological patients from before an in-hospital period to two months after discharge. NN offered extra information, coordination, logistic services and emotional talk. Semi-structured interviews provided data to the primarily open-minded analysis.

Results

Not all could use the help from NN. Those who could, attached affectional bonds to NN and experienced benefit from her presence as well as her help. Many had a feeling of deep-felt disappointment and felt rejected when the contact to NN stopped.

Conclusion

Resources for NN should be prioritized to patients who can use the help, and not stop prematurely. The traditional division and thinking by healthcare professionals are challenged, if all patients should be helped.

Feasibility and effectiveness of a disease and care management model in the primary health care system for patients with heart failure and diabetes (Project Leonardo)

Purpose

Project Leonardo represented a feasibility study to evaluate the impact of a disease and care management (D&CM) model and of the introduction of “care manager” nurses, trained in this specialized role, into the primary health care system.

Patients and methods

Thirty care managers were placed into the offices of 83 general practitioners and family physicians in the Apulia Region of Italy with the purpose of creating a strong cooperative and collaborative “team” consisting of physicians, care managers, specialists, and patients. The central aim of the health team collaboration was to empower 1,160 patients living with cardiovascular disease (CVD), diabetes, heart failure, and/or at risk of cardiovascular disease (CVD risk) to take a more active role in their health. With the support of dedicated software for data collection and care management decision making, Project Leonardo implemented guidelines and recommendations for each condition aimed to improve patient health outcomes and promote appropriate resource utilization.

Results

Results show that Leonardo was feasible and highly effective in increasing patient health knowledge, self-management skills, and readiness to make changes in health behaviors. Patient skill-building and ongoing monitoring by the health care team of diagnostic tests and services as well as treatment paths helped promote confidence and enhance safety of chronic patient management at home.

Conclusion

Physicians, care managers, and patients showed unanimous agreement regarding the positive impact on patient health and self-management, and attributed the outcomes to the strong “partnership” between the care manager and the patient and the collaboration between the physician and the care manager. Future studies should consider the possibility of incorporating a patient empowerment model which considers the patient as the most important member of the health team and care managers as key health care collaborators able to enhance and support services to patients provided by physicians in the primary health care system.

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue

BACKGROUND

Opioid-dependent patients often have co-occurring chronic illnesses requiring medications that interact with methadone. Methadone maintenance treatment (MMT) is typically provided separately from medical care. Hence, coordination of medical care and substance use treatment is important to preserve patient safety.

OBJECTIVE

To identify potential safety risks among MMT patients engaged in medical care by evaluating the frequency that opioid dependence and MMT documentation are missing in medical records and characterizing potential medication-methadone interactions.

METHODS

Among patients from a methadone clinic who received primary care from an affiliated, but separate, medical center, we reviewed electronic medical records for documentation of methadone, opioid dependence, and potential drug-methadone interactions. The proportions of medical records without opioid dependence and methadone documentation were estimated and potential medication-methadone interactions were identified.

RESULTS

Among the study subjects (n = 84), opioid dependence documentation was missing from the medical record in 30% (95% CI, 20%-41%) and MMT documentation was missing from either the last primary care note or the last hospital discharge summary in 11% (95% CI, 5%-19%). Sixty-nine percent of the study subjects had at least 1 medication that potentially interacted with methadone; 19% had 3 or more potentially interacting medications.

CONCLUSION

Among patients receiving MMT and medical care at different sites, documentation of opioid dependence and MMT in the medical record occurs for the majority, but is missing in a substantial number of patients. Most of these patients are prescribed medications that potentially interact with methadone. This study highlights opportunities for improved coordination between medical care and MMT.

Integrated primary care in Germany: the road ahead

PROBLEM STATEMENT

Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult.

DESCRIPTION OF POLICY DEVELOPMENT

Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and 'community medicine nurses'.

CONCLUSION AND DISCUSSION

Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans-sectoral education and training of providers.

Primary care physicians' links to other physicians through Medicare patients: the scope of care coordination

BACKGROUND

Primary care physicians are expected to coordinate care for their patients.

OBJECTIVE

To assess the number of physician peers providing care to the Medicare patients of a primary care physician.

DESIGN

Cross-sectional analysis of claims data.

SETTING

Fee-for-service Medicare in 2005.

PARTICIPANTS

2284 primary care physicians who responded to the 2004 to 2005 Community Tracking Study Physician Survey.

MEASUREMENTS

Primary patients for each physician were defined as beneficiaries for whom the physician billed for more evaluation and management visits than any other physician in 2005. The number of physician peers for each physician was the sum of other unique physicians that the index physician's primary patients visited plus other unique physicians who served as the primary physician for each of the index physician's nonprimary patients during 2005.

RESULTS

The typical primary care physician has 229 (interquartile range, 125 to 340) other physicians working in 117 (interquartile range, 66 to 175) practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician. When only the 31% of a primary care physician's primary patients who had 4 or more chronic conditions was considered, the median number of peers involved was still substantial (86 physicians in 36 practices). The number of peers varied with geographic region, practice type, and reliance on Medicaid revenues.

LIMITATIONS

Estimates are based only on fee-for-service Medicare patients and physician peers, and the number of peers is therefore probably an underestimate. The modest response rate of the Community Tracking Study Physician Survey may bias results in unpredictable directions.

CONCLUSION

In caring for his or her own primary and nonprimary patients during a single year, each primary care physician potentially must coordinate with a large number of individual physician colleagues who also provide care to these patients.

FUNDING

National Institute on Aging, American Medical Group Association, and the Robert Wood Johnson Foundation.

Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients

OBJECTIVES

To investigate patients' experience with coordination of their postsurgical care across multiple settings and the effects on key outcomes.

DATA SOURCES

Primary data collected over 18 months from 222 unilateral knee-replacement patients at Brigham and Women's Hospital in Boston, MA.

STUDY DESIGN

Patients were surveyed about the coordination of their postdischarge care during the 6-week period postdischarge when they received care from rehabilitation facilities and/or home care agencies and follow-up care from the surgeon.

DATA COLLECTION

Patients were surveyed before surgery and at 6 and 12 weeks postsurgery.

PRINCIPAL FINDINGS

Patient reports highlight problems with coordination across settings and between providers and themselves. These problems, measured at 6 weeks, were associated with greater joint pain, lower functioning, and lower patient satisfaction at 6 weeks after surgery. At 12 weeks after surgery, coordination problems were associated with greater joint pain, but were not associated with functional status.

CONCLUSION

Coordination across settings affects patients' clinical outcomes and satisfaction with their care. Although accountable for transfer to the next care setting, providers are neither accountable for nor supported to coordinate across the continuum. Addressing this system problem requires both introducing coordinating mechanisms and also supporting their use through changes in providers' incentives, resources, and time.

Triphasic waves in cerebral carcinomatosis. Another nonmetabolic cause

A 59-year-old woman with a metastatic adenocarcinoma of unknown origin and no metabolic abnormalities developed a diffuse encephalopathy, with generalized triphasic waves seen on the electroencephalogram. Postmortem examination revealed widespread, multifocal perivascular carcinomatosis of the cerebral cortices. Triphasic waves have been described with dementing processes, subdural hematomas, and cerebrovascular disease, but they are more commonly seen with metabolic encephalopathies. This case demonstrates an additional nonmetabolic cause of triphasic waves.