Welcome to Care Coordination and Interoperable Health IT Systems, Overview of Care Coordination. This is Lecture a, What is Care Coordination? Thank you for taking your valuable time to invest in learning what it means to coordinate care. As you view and learn from this webinar, you will become better navigators, to better guide and coordinate care for patients traveling through the complex and often frightening health care maze. The objectives for this unit, Overview of Care Coordination, Lecture a, are to define care coordination effectiveness, explain the purposes for care coordination. This unit provides insight into what is known and tested about patient centered care coordination. We'll learn about care coordination implementation in a variety of care settings and programs, from what is being tried, tested, and applied by those already on the care coordination journey. Case examples represent a range of programs and demonstrate care coordination successes. According to Thomas Bodenheimer from work titled Coordinating Care: A Perilous Journey in the Health Care System, care coordination is defined as the deliberate integration of patient care activities between two or more participants involved in a patient's care to facilitate the appropriate delivery of health care services. The image of the maze represents how in health care, critical information transfer roles and responsibility can sharply and suddenly shift among members of your own medical home team. From the reception, to nurse, to physician, to across the settings for specialty care, hospitals, and emergency departments. As such, each care coordination role is valuable in helping patients navigate the healthcare maze. As defined by the Agency for Healthcare Research and Quality, AHRQ, care coordination involves deliberately organizing patient care activities, and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient. Additionally, care coordination focuses on the transitions between care and is a specific part of care management. Care management, in turn, is an umbrella term for broader efforts at improving the quality of care provided to patients, while decreasing avoidable costs associated with care delivery. We can begin with the case example of coordinated care from the Association for Healthcare Research and Quality's Care Coordination Measurement Atlas. In this case, Mr. Andrews is a 70 year old man with congestive heart failure and diabetes. He uses a cane when walking and recently has had some mild memory problems. During a recent meal delivery, the program staffer noticed that Mr. Andrews seemed very ill. He called an ambulance and Mr. Andrews was taken to the emergency department. There he was diagnosed with a congestive heart failure exacerbation and was admitted. The hospital contacts Mr. Andrews' primary care physician, or PCP, who is immediately available to coordinate care. The PCP noted that Mr Andrews may have had dosing changes after a recent appointment with his cardiologist. In addition, the PCP noted that Mr Andrews may be missing medication doses because of his forgetfulness. He provided the hospital team with contact information for specialists, and asked that a record of Mr. Andrews' hospital stay be sent to his office upon discharge. Before release, Mr. Andrews is given instructions, and his daughter is informed of next steps, so she, too, can be involved in Mr. Andrews' care coordination. Evidence based care coordination allows for seamless transitions across the health care continuum in a deliberate effort to improve outcomes and reduce errors and redundancies. Care coordination's purpose is to develop collaborative health-partnership relationships, well structured processes, and integrated health information technology systems, to meet patient's healthcare needs when and where the patient needs and desires care. Care coordination can ensure multidisciplinary health team's optimum collaboration with communication of pertinent health information over time between the health care team's discipline settings and patients and their family members when appropriate. The care coordination aim is to provide continuity of care in meeting health care plan goals, and achieve positive patient health and experience outcomes. Care coordination provides necessary access to personalized clinically documented care continuity information that is coordinated and securely integrated across healthcare systems. Safety Net Medical Home defines care coordination as beginning with the thoughtful identification of key service providers in the community, followed by the deliberate organization of patient care activities between two or more participants involved in a patient's care to facilitate the appropriate delivery of healthcare services. Care coordination collaborative role. Care coordination is taking the responsibility and accountability role for coordinating, consulting, and collaborating with healthcare teams, and the patient and family, when appropriate, to meet an individual's healthcare needs over time by collectively addressing the individual's medical and social determinants of health. Care coordination begins with proactive collaboration with the patient and the recognized multi-disciplinary healthcare team who recognize the patient as a member of the team. The expanded care team may include the family when appropriate, physician specialists, facilities such as hospital and hospitalist physicians, emergency departments and emergency physician specialists, nursing homes, skilled care facilities, rehabilitation facilities, home health and community based services, home attendants, hospice programs, facility case managers, discharge planners, care coaches, care transition navigators, mental health providers, pharmacists, community health workers, community resource teams, payer-based service coordinators and others. As Christine Bechtel from the National Partnership for Women and Children expressed, patients just want doctors to talk to each other. Pediatric Care Coordination is a patient and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families. Care coordination addresses inter related medical, social, developmental behavioral, educational, and financial needs to achieve optimal health and wellness outcomes. Consider the case example of Julia and Paul, and their three children. Julia lost her job six months ago, and Paul works part time. They do not have health coverage, but their children are enrolled in CHIP, the Children's Health Insurance Program or Children's Medicare. Their son John is 12 years old and has severe asthma. He ends up in the emergency room at least once a month. The inhalers the doctor prescribes are expensive. Paul thinks the mold growing in their living room might be exacerbating John's asthma, but he has not been able to get their landlord on the phone to address the problem. The primary care practice that John visits for medical care has adopted comprehensive care coordination. During one of his visits, a care coordinator sits down with John, Julia, and Paul and assesses all of John's health needs to determine if there are any other services that could help John stay healthy and out of the emergency room. The care coordinator's conversation with John and his parents reveals the significant psychological, social, and economic factors that might be aggravating John's condition. The care coordinator connects John to a behavioral health specialist to discuss why he might be having trouble sleeping, legal services to address the families' trouble with their landlord, a pharmacist to discuss if there are more affordable pharmaceutical interventions, and a social worker to connect the family with other community benefit programs they qualify for, to try to lighten the strain on the family budget. All of these professionals update John's electronic medical record as they make progress assisting the family. The pharmacist sees what medication John had been taking and sends a secure message to the physician to ask if a particular more affordable substitute would work. The behavioral health specialist talks with the social worker about enrolling John in an after school program in their community that teaches teenagers living with moderate to severe asthma to swim as a form of therapy. The electronic database that stores this information will send reminders to the care coordinator to follow up with John's family and to check on how he is feeling and the progress of these new treatment efforts. The Triple Aim of Care Coordination is improving the patient experience of care, improving the health of populations, and reducing per capita cost of health care. Care coordination should be a team and family driven process that improves patient, family and health care practitioner satisfaction, facilitates children's and youth's access to services, improves healthcare outcomes, and reduces costs associated with healthcare fragmentation which can lead to under and over utilization of care. Whole Person Care Coordination includes A, comprehensive care, B, collaborative self-management support, and C, emphasis on the spectrum of care needs in multiple settings across the care continuum and community, such as preventive, routine, acute, urgent and emergent care, mental and behavioral health, advice, assistance, education, and support for making changes in health habits and making all whole person shared decisions and goals. Whole person care includes provision of comprehensive body, mind, and spirit health-care. Whole person care best practices focus on always being person-centered, providing a personal clinician for oversight of continuous comprehensive whole-person care, coordinating and integrating care in multiple care settings across the healthcare system, providing team-based care to include the person and their family when appropriate, centrally as part of the team, and, sharing care decisions. Preventive whole person care coordination is a key component and a guiding principle of the expectation for multidisciplinary clinician teams' focus. Primary care physicians represent the majority of team leaders for whole person care coordination teams in the Patient Centered Medical Home, PCMH, or Health Home Team Model. PCMHs function as the repository holding information for measurement, target health goal setting and shared decision making teams using whole person health information. Primary care physician team leaders may include family practitioners, general practitioners, internists and pediatricians, other multi disciplinary team members may also be care coordination team leaders. Models for coordinating care for poorly controlled or complex conditions include special needs frail pediatric patients, chronically ill patients, and patients requiring high health care utilization. Older patients with chronic disease need particularly complex care coordination as they often see many specialists and have lengthy medical histories. Ms H is a 55 year old grandmother with a 12 year history of Type 2 diabetes, complicated by elevated blood pressure and recurrent episodes of major depression. Her PCP postponed adjusting her hypoglycemic and anti-hypertensive drug doses until her depression was under better control, and referred her to the mental health center. Mrs. H's primary care physician had previously met with the clinical director of the mental health center. The center's psychiatrist was shown how to log in to and use the practices' web based e-referral system. The referral coordinator worked with Ms. H and the appointment clerk at the mental health center to set up an appointment that week. Ms. H missed her appointment because one of her grandchildren was ill. The e-referral system noted her missed appointment and the referral coordinator called Ms. H to set up another appointment. When Ms. H saw Dr. P, he had her clinical information in front of him. He adjusted her depression medication, but also found that her blood pressure was elevated. Ms. H also complained of headache and fatigue. Dr. P became alarmed about her blood pressure and headache and arranged for her to be seen that afternoon by her PCP, who adjusted her anti-hypertensive medications. The receptionist referral coordinator suggested that Ms. H have her BP checked by the EMT's at the neighborhood fire station every other day, which she did. Ms H slowly began to feel less depressed and her BP slowly came down to target levels with one more medication adjustment. Care coordination comprises variable components across states and systems of care and can be provided by a great range of professional and non-professional staff supported by various payers and forms of payment. Care coordination facilitated through the meaningful use of information technology systems can protect and provide necessary and timely protected, or individually identifiable health information, PHI. PHI can be measured, analyzed and used to provide quality and safety improvement in care coordination and healthcare delivery. The current provider may disclose the relevant PHI to prospective recipient providers such as by using certified EHR technology, or disclosing the PHI using other means. This disclosure is a treatment disclosure in anticipation of future treatment of the patient by the rehabilitation facility and thus may be carried out under 45 CFR 164.506(c)(2). Additional detail on PHI and care coordination are in unit 10 of this component. Information used in care coordination may include demographics, patient experience notes, clinical documentation notes, medication management information, registries information, utilization, and more. Care coordination system essentials include the use of patient health information and technology systems to support care coordination should be standardized and consistent. Health information technology systems capabilities should be well aligned with the clinician's priorities. Care coordination should include interoperable systems to share information, adequate financial support, and HIT workforce expertise is necessary to sustain care coordination systems. Care coordination also requires guiding patients beyond the practice setting through cooperative alliances with essential healthcare services that meet a complete range of needs for a given patient population. Additionally, the development of relationships and structured processes that ensure collaboration, coordination, and communication between the primary care physician team leader and the patient as a part of the team, and with the physician's facilities and services outside of the primary care physician's practice setting. This concludes Lecture a, What is Care Coordination, of Unit 1, Overview of Care Coordination. In summary, care coordination requires collaboration and communication between the primary care physician team leader, care team, and the patient. Care coordination is successful when the right information is available, supported by health IT systems, for decision making.
