Care Coordination - Northwest Medical Partners

NW AHEC Practice Transformation Series Building Medical Homes Together
Care Coordination in the Medical Home NCQA PCMH Standard 5

Presented by:
Tamela Yount, MSHAI, PCMH-CCE
Practice Support Coordinator
Wake Forest School of Medicine
NW AHEC
tyount@wakehealth.edu

Objectives
Introduce the Concept of Care Coordination
Understand why we need to coordinate care
Introduce the Care Coordination Model
Understand how the Care Coordination Model is implemented in a PCMH

Defining Care Coordination
Closing the Quality Gap:
A Critical Analysis of Quality Improvement Strategies
Volume 7—Care Coordination
Identified around 50 different definitions

Defining Care Coordination
“The deliberate organization of patient care
activities between two or more participants
involved in a patient’s care to facilitate the
appropriate delivery of health care services.”
~McDonald, 2007
+
+
+

Another perspective….
Care coordination is a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.“
~ National Quality Forum 2006

Primary Care Team
Another perspective….
Patient/
Families
In home
Care-givers
Religious Spiritual Support
Education Services
Medical Supply Companies
Mental
Health Providers
Hospitals and other Facilities
Legal System Support
County/
Social Services
Community Services
Ancillary Providers/
Services (OT, PT, Labs, Imaging, etc)
Pharmacies/
Pharmacy Benefit Managers
Utilization Management/
Payers
Specialty Practices

Five Key Elements of Care Coordination
Numerous participants are typically involved in care coordination;
Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient’s care;
In order to carry out these activities in a coordinated way, each participant needs adequate knowledge about their own and others’ roles, and available resources;
In order to manage all required patient care activities, participants rely on exchange of information; and
Integration of care activities has the goal of facilitating appropriate delivery of health care services.
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Volume 7—Care Coordination)
http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf

Participants
Patients
Family Caregivers
Healthcare Providers: Physicians, PAs, NPs, etc.
Clinical Support Staff: Nurses, CMAs, MAs, etc.
Support Staff/Administrative Staff
Pharmacists, PharmDs (Clinical Pharmacists)
Social Workers, Counselors, Diabetic Educators, etc.
Other Professionals and Ancillary Providers

Interdependence of Participants
Coordination for patients with complex health care needs often involves multiple participants who individually provide specialized knowledge, skills, and services, and who together potentially provide a comprehensive, coherent, and continuous response to a patient’s unique care needs.

Roles and Resources
Timely and Appropriate Medical Decisions Require
Information about Available Resources
Information about the experience, skills, plans, relationships, and preferences of all participants to develop care plan
Adequate knowledge about roles and interdependencies among participants
ways to reduce system weaknesses and barriers through “bridging gaps” in information flow

Information Exchange
Exchange of critical patient- related information is essential to facilitate effective coordination and medical decision making.

Care Coordination Goal (AIM)
Right Services
Right Order
Right Time
Right Setting
The ultimate goal of Care Coordination is the appropriate delivery of health care…..

Why work on Care Coordination?
Safety & quality
Practice environment
Patient experience
Wasted Resources
Reducing Care Fragmentation: Presentation on Coordinating Care
MacColl Institute for Healthcare Innovation
Group Health Research Institute
http://www.improvingchroniccare.org/downloads/care_coordination_toolkit_presentation.ppt

Are any of these common in your practice?
You don’t know the people to whom you are referring patients.
Specialists complain about the information you send with a referral.
You don’t hear back from a specialist after a consultation.
Your patient complains that the specialist didn’t seem to know why s/he was there.
A referral doesn’t answer your question.
Your patient doesn’t come back to see you after a consultation.
A specialist duplicates tests you have already performed.
You are unaware that your patient was seen in the ER.
You were unaware that your patient was hospitalized.

Patients Report Experiencing Poor
Coordination
Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.
Percent U.S. adults reported in past two years:
No one contacted you about test results, or
you had to call repeatedly to get results
Test results/medical records were not
available at the time of appointment
Your primary care doctor did not receive a
report back from a specialist
Any of the above
25
21
19
15
13
47
0 20 40 60
Doctors failed to provide important
medical information to other doctors or
nurses you think should have it
Your specialist did not receive basic medical
information from your primary care doctor

37
75
82
61
68
62
76
0
25
50
75
100
AUS CAN GER NETH NZ UK US
Percent reporting that they receive information back for “almost all” referrals
(80% or more) to Other Doctors/Specialists:
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Commonwealth Survey of PCPs

What constitutes a high quality referral or transition?
Institute of Medicine’s (IOM) report Crossing the Quality Chasm: A New Health System, for the 21st Century:
Safe
Planned and managed to prevent harm to patients from medical or administrative errors.
Effective
Based on scientific knowledge, and executed well to maximize their benefit.
Timely
Patients receive needed transitions and consultative services without unnecessary delays.
Patient-centered
Responsive to patient and family needs and preferences.
Efficient
Limited to necessary referrals, and avoids duplication of services.
Equitable
The availability and quality of transitions and referrals should not vary by the personal characteristics of patients.

How? The Care Coordination Model

Key Changes
Assume accountability
Provide patient support
Build relationships & agreements
Develop connectivity

#1 Assume Accountability
Decide as a primary care clinic to improve care coordination.
Develop a referral/transition tracking system.

#2 Provide Patient Support
Organize the practice team to support patients and families during referrals and transitions.
Referral coordinator:
Tracks all referrals and transitions
Provides patient (and family) with information about referral
Addresses barriers to referrals
Follows up on missed appointments

Three Levels of Patient Support
Clinical Care Management
Logistical
Logistical
Logistical
Clinical Monitoring
Care Coordination
Clinical Follow-up Care
Medication Mgmt
©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
Self-mgmt Support
Clinical Monitoring

Team Responsibilities
Helping patients identify sources of service—especially community resources
Helping make appointments
Tracking referrals and helping to resolve problems
Assuring transfer of information (both ways)
Monitoring hospital and ER utilization reports
Managing e-referral system
http://www.safetynetmedicalhome.org/sites/default/files/Webinar-Care-Coordination.pdf

#3 Build Relationships & Agreements
Identify, develop and maintain relationships with key specialist groups, hospitals and community agencies.
Develop agreements with these key groups and agencies.
Lessons learned:
Talk through the process for a “typical” patient case
Focus on the system and not the people

Where might you start?
Community Agencies?
Tracking & following up on lab/imagining results;
Identification & tracking of linkages to community resources.
Medical Specialists?
Guidelines for referral, prior tests, and information;
Expectations about future care and specialist-to-specialist referral;
Expectations for information back to PCMH.
EDs/ Hospitals?
Notification of visit/admission and discharge;
Medication reconciliation after transition;
Involvement of PCMH in post-discharge care.

#4 Develop Connectivity
Develop and implement an information transfer system.
Key elements of system:
Integrates information needs and expectations (per agreements)
Assures that information transmits to correct destination
Key milestones in the referral process can be tracked
Referring clinicians and consultants can communicate with each other

PCMH Standard 5 Track and Coordinate Care
Element A : Test Tracking and Follow-up
Element B : Referral Tracking and Follow-up
Element C : Coordinate with Facilities and Manage Care Transitions

PCMH Standard 5 Element A: Test Tracking and Follow-up
•Overdue Results – Flagging and Follow-up
•Abnormal Results – Alerting provider
Lab Tracking (Factors 1 & 3)
•Overdue Results – Flagging and Follow-up
•Abnormal Results – Alerting Providers
Imaging Tracking (Factors 2 & 4)
•Normal Results
•Abnormal Results
Patient Notification of Results

PCMH Standard 5 cont’d Element A: Test Tracking and Follow-up
•Lab Orders/Results
•Imaging Orders/Results
•Newborn hearing and blood-spot screening (NA for Adult Practices)
Electronic Communication with Facilities
•40% of Lab Results as Structured Data Elements
•MU Menu Measure
•Imaging Test Results (can be a scanned PDF)
Electronically incorporates results into EHR (Must be able to retrieve and review from your system)

PCMH Standard 5 Element B: Referral Tracking and Follow-up
Communicating Pertinent Clinical Information and Reason for Referral with the Specialists or Consultants
Referral Tracking & Follow-up to obtain reports
Specialist Agreements (Co-Management)
Asking patients about self-referrals
Electronic Exchange of Key Clinical Information – MU Core Measure (Stage 1)
Electronic Summary of Care for more than 50% of referrals – MU Menu Measure (Stage 1)

PCMH Standard 5 Element C: Coordinate with Facilities and Manage Care Transitions
Identify patients with hospital admissions or ED visits
Share clinical information with hospitals and ED Departments
Obtain Discharge Summaries from hospitals or other facilities
Contact patients/families for follow-up care following discharge from hospital or ED
Exchanges patient information with hospital during hospitalizations
Collaborates with patients/families to develop “transition of care” plan from pediatric to adult care (NA for Adult only practices)
Electronic Exchange of Key Clinical Information with facilities
Electronic Summary of Care Record for more than 50% of care transitions MU Menu Measure (Stage 1)

Resources
Reducing Care Fragmentation: Presentation on Coordinating Care
http://www.improvingchroniccare.org/downloads/care_coordination_toolkit_presentation.ppt
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Volume 7— Care Coordination)
http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf
Improving Chronic Illness Care: Care Coordination Webpage
http://www.improvingchroniccare.org/index.php?p=Care_Coordination&s=326
Safety Net Medical Home Care Coordination Homepage
http://www.safetynetmedicalhome.org/change-concepts/care-coordination
ARHQ Care Coordination Measures Atlas
http://www.ahrq.gov/professionals/systems/long-term-care/resources/coordination/atlas/care- coordination-measures-atlas.pdf

Care Coordination - Northwest Medical Partners

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