HI-FIVE (Health Informatics For Innovation, Value & Enrichment) Training is a 12-hour online course designed by Columbia University in 2016, with sponsorship from the Office of the National Coordinator for Health Information Technology (ONC). The training is role-based and uses case scenarios. Also, it has additional, optional modules on other topics of interest or relevance. Although we suggest to complete the course within a month's timeframe, the course is self-paced and so you can start and finish the course at anytime during a month's time period. No additional hardware or software are required for this course. Our nation’s healthcare system is changing at a rapid pace. Transformative health care delivery programs depend heavily on health information technology to improve and coordinate care, maintain patient registries, support patient engagement, develop and sustain data infrastructure necessary for multi-payer value-based payment, and enable analytical capacities to inform decision making and streamline reporting. The accelerated pace of change from new and expanding technology will continue to be a challenge for preparing a skilled workforce so taking this training will help you to stay current in the dynamic landscape of health care. This course is one of three related courses in the HI-FIVE training program, which has topics on population health, care coordination and interoperability, value-based care, healthcare data analytics, and patient-centered care. Each of the three courses is designed from a different perspective based on various healthcare roles. This first course is from a clinical perspective, geared towards physicians, nurse practitioners, physician assistants, nurses, clinical executives and managers, medical assistants, and other clinical support roles. However, we encourage anyone working in healthcare, health IT, public health, and population health to participate in any of the three trainings. If you would like to obtain continuing medical education (CME) or continuing nursing education (CNE) credits, you will need to have eligible credentials, complete the entire course, and complete the evaluation survey at the end. The HI-FIVE team verifies after each month that these requirements have been met and then a separate certificate (fee may apply) is distributed to you from our accreditation office. Please allow time for processing. If you have any further questions about continuing education, please see our website at www.hi-fivetraining.org. Accreditation Statement The College of Physicians and Surgeons of Columbia University is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. AMA Credit Designation Statement The College of Physcians and Surgeons designates this enduring material for 12.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The planning committee members are: Rita Kukafka, DrPH, MA, FACMI; Bruce Forman, MD; Gil Kuperman, MD, PhD; Virginia Lorenzi, MS, CPHIMS, FHL7, and Victoria Tiase, MSN, BN. None of the members of the committee, who planned this CME Activity, have any relevant financial relationships to disclose. The release date is 2/1/17 and the expiration date is 1/31/18. This activity is eligible for 12 continuing nursing education (CNE) credits. Columbia University School of Nursing, Continuing Nursing Education Program is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
What is Care Coordination?
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HI-FIVE: Health Informatics For Innovation, Value & Enrichment (Clinical Perspective)
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Mr. Osner Santana Meets Dr. Jefferson (Part 1)
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Rita KukafkaAssociate Professor
Biomedical Informatics
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.
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