Soraya Ghebleh - Clinical Integration and Care Coordination


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Here is a simple slidedeck of research done that examined which systemic care coordination practices should be maximized according to the literature to improve clinical integration within and between healthcare organizations.

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Soraya Ghebleh - Clinical Integration and Care Coordination

  1. 1. Which systemic care coordination strategies should be maximized to improve clinical integration in hospitals and integrated healthcare delivery systems? Soraya Ghebleh May 29, 2013 The Dartmouth Institute for Health Policy and Clinical Practice
  2. 2.  Background  Trends in Current Healthcare Environment  Clinical Integration  Systemic Care Coordination Strategies  Conceptual Framework  Methods and Search Strategy  Overview  Inclusion Criteria  Search Results  Limitations  Results  Characteristics of Included Studies  Summary of Results  Methodological Quality  Synthesis  Completeness and Applicability of the Evidence  Common Themes of Care Coordination Interventions  Recommendations  Implications for Institutions Interested in Clinical Integration  Framework to Improve Clinical Integration using Systemic Care Coordination Strategies  Conclusions  Future Research Executive summary
  3. 3.  Trend #1: Fragmented Delivery of Care  Trend #2: Healthcare Reform  Trend #3: Increased Consolidation Activity Three Current trends Shaping the healthcare environment
  4. 4. AIM: To bring providers together to manage care in a more standardized, coordinated, effective, and efficient manner, leading to improvement in quality for patients. PRIMARY CHARACTERISTICS AS DEFINED BY THE FEDERAL TRADE COMMISSION: (1)Ability to achieve significant clinical and economic efficiencies (2)Broad physician representation and physician intervention (3)A well-developed care management program that uses evidence-based guidelines (4)A data management system that enables extensive data collection, information sharing, and utilization review clinical integration and quality
  5. 5. Care Coordination is defined as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.”1 Mechanism by which clinical integration can be improved through comprehensive interventions Systemic care coordination strategies involve collaboration between multiple disciplines within an institution or between institutions Care coordination 1 Source: Care Coordination, Quality Improvement: Structured Abstract. June 2007. Agency for Healthcare Research and Quality, Rockville, MD.
  6. 6. Conceptual framework
  7. 7. A systematic review of the available literature in the Business and Medical databases was performed in April 2013. The specific databases searched were MEDLINE via PubMed, ABI/Inform, Business Source Complete, and CINAHL. A search strategy and specific inclusion criteria were established a priori. All databases were searched from 1990-2013. Search terms utilized were “integration,” “care coordination,” “hospitals,” and “healthcare systems.” The Boolean terms “AND” and “OR” were used to find intersection between these terms overview of methods
  8. 8. Studies were included that met the following criteria: (1) study designs consisting of randomized controlled trials, cohort studies, case-control studies, before-after studies, pseudo-experimental or non- randomized trials, cross-sectional studies, and case studies (2) intervention must fall under one of the five broad approaches of care coordination as identified by the Agency for Healthcare Research and Quality (3) intervention must aim to further integrate setting where intervention is being implemented (4) intervention must be limited to hospital-wide settings, integrated health systems or a hospital clinic setting that involves multi-disciplinary collaboration (5) intervention must be a systemic intervention (6) studies were limited to 1990 to April 2013. Inclusion criterion
  9. 9. results of search 77 studies were identified from ABI/Inform, 185 studies from MEDLINE via Pubmed, 193 from CINAHL, and 136 from Business Source Complete. A total of 592 records were identified through a database search and 94 duplicates were removed. A remaining 498 studies were then screened by title and abstract. 441 studies were excluded and 57 remaining full text articles were then screened for eligibility. Of the 57 full text articles that were screened, 13 met the inclusion criteria.
  10. 10. Numerous definitions for both clinical integration and care coordination exist in the literature Lack of consensus on appropriate measures of clinical integration Deficit of high-quality, empirical studies measuring the effects of care coordination on clinical integration Review was performed by only one individual, leaving room for potential error limitations of search Strategy
  11. 11. Interventions all met one of the five broad categories of care coordination interventions as defined by the Agency for Healthcare Research and Quality Outcomes of all studies included at least one of the four components of clinical integration as defined by the Federal Trade Commission Five of the thirteen studies examined interventions implemented across an integrated delivery system Six studied single institution interventions Two studies compared multiple settings Characteristics of included studies
  12. 12. characteristics of included studies
  13. 13. summary of results All studies gave insight into the design and implementation of care coordination interventions Varied reporting of quantitative results across studies Metrics reported included length of stay, hospital utilizations, patient satisfaction, staff satisfaction, ED presentations, and cost savings Each study gave in-depth descriptions of care coordination interventions, processes used to develop these interventions, and recommendations
  14. 14.  A standardized abstraction tool adapted from Downs and Black was utilized to assess the methodological quality of each study  Many studies included were of low quality, had limited reporting of quantitative results, and lacked generalizability  Difficult to find the best study design to assess the link between care coordination and clinical integration due to the limited amount of existing studies as well as the numerous metrics that can be utilized to assess this link  Reporting bias is a concern as specific positive outcomes were often reported but adverse outcomes were not  Conflict of interest was also of concern, as only four studies specifically stated that no conflict of interest was present methodological quality
  15. 15. Methodological quality  High Risk  Low Risk  Unclear  N/A
  16. 16.  Eligible studies all incorporated at minimum one component of the categories of care coordination interventions and one component of the characteristics of clinical integration as an aim  Certain components of both care coordination and clinical integration were studied more than others completeness of evidence  Unclear if the care coordination intervention was the only factor that affected clinical integration in the study setting  The appropriate study design to study the link between systemic care coordination interventions and improving clinical integration has not been determined in the literature
  17. 17. Institutions are consolidating to meet new demands in the healthcare environment and must become more efficient to remain competitive Improving clinical integration through carefully implemented systemic care coordination strategies can lead to higher quality and satisfaction and has the potential to reduce costs Care coordination strategies to improve clinical integration within a hospital can be applied systematically across a delivery system If an institution that is part of a system implements a strategy or intervention and success is reasonably demonstrated, that institution can expand or share that strategy within the system clinical integration within and between institutions
  18. 18. Despite variations in quality and generalizability of included studies, the synthesis revealed common components of interventions regardless of study design or setting:  Leadership  Communication  Data Collection and Meaningful Utilization  Flexibility  Process Improvement  Patient-Centered Emphasis Common themes of care coordination interventions
  19. 19. Guidelines for improving clinical integration through systemic care coordination strategies
  20. 20. Establish leadership before implementation of intervention Leadership can be senior management, clinical leaders, care coordinators, or teams but must be clear to the staff Responsibilities include setting institution and organizational goals, creating an organizational structure, and ensuring appropriate management of various components of the intervention Oversight and monitoring of the intervention is essential Leadership
  21. 21. Frequent staff meetings that incorporate all levels of staff High-touch communications strategy that emphasizes institutional goals and a culture of learning and adaptability Cross-department communication pathways established Sharing best practices between institutions within an integrated delivery system Establish communication between patient and individual or team that serves as single point of care communication
  22. 22.  Data collection is essential to any quality improvement initiative  Defined metrics should be established and data collection should begin prior to any intervention  Data should be benchmarked with institutional and national data  Real-time data collection allows for adaptive learning and necessary adjustments to be implemented  Effective utilization of healthcare information technology to ensure data is being collected efficiently data collection & meaningful utilization
  23. 23. Flexibility is necessary in two contexts:  (1) Institutional Flexibility  (2) Point of Contact for Patient flexibility Institutions require adaptability with implementation of interventions, as no two settings are entirely homogeneous The point of contact for the patient must have the ability to span departments to ensure proper management of patient care Beneficial for care coordination staff or intervention leadership to give an outside perspective on pathways and processes occurring in the institution
  24. 24. process improvement Adaptive learning to adjust, enhance, and improve implemented interventions Incorporation of data collection, staff and patient feedback, evidence from the literature, and existing clinical pathways to strive for improved outcomes and efficiency Process improvement measures should be performed as problem areas are defined and should be adapted as data is collected
  25. 25. patient-centered emphasis Goal of any intervention is ultimately to improve outcomes and quality for patients Comprehensive care management plans should be designed for high-risk and high-utilizing patients  Patient feedback is informative for improvement and can provide insight beyond the perspective of providers  Patient and caregiver satisfaction should be kept in mind with any intervention designed to improve patient care and overall experience  Patient care pathway is integral to any systemic care coordination intervention
  26. 26. More high quality studies with empirical data should be performed Studies should involve comprehensive systemic care coordination interventions that encompass all of the broad categories as defined by the AHRQ Outcomes should be identified and defined before the intervention is implemented and an adequate time period should be established for follow- up A standardized, validated, systematic, evidence-based tool needs to be developed to effectively evaluate integration in order to compare different hospitals and integrated delivery systems Future research
  27. 27.  Relationship between care coordination and clinical integration is important in the context of healthcare reform and increased consolidation  These different components can be used to develop a comprehensive, systemic, care coordination plan that has the potential to improve clinical integration within an institution and between institutions conclusions  There is no identical, repeatable care coordination plan guaranteed to work in every institution  Further research and higher-level study should be performed as coordinating care at a systemic level shows great promise to improve the quality and experience of healthcare delivery