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

[email protected]

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

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


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

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




HOW DOES THIS RELATE TO PCMH?

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




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







http://www.improvingchroniccare.org/index.php?p=Care_Coordination&s=326



















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