2D5 Care Coordination 2014

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 7Care Coordination
Identified around 50 different definitions
Defining Care
Coordination
The deliberate organization of patient care
activities between two or more participants
involved in a patients care to facilitate the
appropriate delivery of health care services.
~McDonald, 2007
Another perspective.
Care coordination is a function that helps ensure that
the patients 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
Another perspective.
Mental
Health
Providers
Medical
Supply
Companies
Hospitals
and other
Facilities
In home
Care-givers
Primary Care Team
Pharmacies/
Pharmacy
Benefit
Managers
Patient/
Families
Utilization
Management/
Payers
Specialty
Practices
Religious
Spiritual
Support
Legal System
Support
County/
Social
Services
Community
Services
Education
Services
Ancillary
Providers/
Services (OT, PT,
Labs, Imaging, etc)
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 patients 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 7Care 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 7Care
Coordination)
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 patients unique care needs.
Roles and Resources

Timely and Appropriate
Medical Decisions Require
Information
about Available
Resources
Information
about the
ways to reduce
Adequate
experience,
system
knowledge about
skills, plans,
weaknesses
and
roles and
relationships,
barriers through
and preferences interdependenci
bridging gaps
es among
of all
in information
participants
participants to
flow
develop care
plan
Information Exchange
Exchange of critical patientrelated information is

essential to facilitate effective
coordination and medical
decision making.
Care Coordination Goal (AIM)
The ultimate goal of Care

Coordination is the appropriate
delivery of health care..
Right
Services
Right
Order
Right
Time
Right
Setting
Why work on Care

Coordination?
Patient experience
Wasted Resources
Safety & quality
Practice environment
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 dont know the people to whom you are referring patients.
Specialists complain about the information you send with a referral.
You dont hear back from a specialist after a consultation.
Your patient complains that the specialist didnt seem to know why s/he
was there.
A referral doesnt answer your question.
Your patient doesnt 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
Percent U.S. adults reported in past two
years:
Your specialist did not receive basic
medical information from your
primary care doctor
Your primary care doctor did not
receive a report back from a
specialist
Test results/medical records
were not available at the time of
appointment
Doctors
failed to provide
important medical information to
other doctors or nurses you think
should
it
No
one have
contacted
you about test
results, or you had to call
repeatedly to get results
Any of the above
urce: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.
Commonwealth Survey of
PCPs
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.
What constitutes a high quality

referral or transition?
Institute of Medicines (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.
Patientcentered
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
http://www.improvingchroniccare.org/downloads/care_coordination_toolkit_present
ation.ppt
#1 Assume
Accountability
Decide as a primary
care clinic to improve
care coordination.
Develop a
referral/transition
tracking system.

http://www.improvingchroniccare.org/downloads/care_coordination_to
olkit_presentation.ppt
#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
MacColl Institute for Healthcare appointments
Innovation

Three Levels of Patient

Support
Clinical Care Management
Clinical Monitoring
Medication Mgmt
Logistical
Self-mgmt Support
Clinical Follow-up Care

Clinical Monitoring
Logistical
Care Coordination
Logistical
MacColl Institute for Healthcare Innovation, Group Health Research

Institute 2011
Team Responsibilities
Helping patients identify sources of serviceespecially
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, behavioral health providers,
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

http://www.improvingchroniccare.org/downloads/care_coordination_toolkit_presentation.ppt
Where might you start?

Community Agencies?
Tracking & following up on
lab/imagining results;
Identification & tracking of linkages
to community resources.
Medical Specialists and Behavioral
Health Providers?
Guidelines for referral, prior tests,
and information;
Expectations about future care and
#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
Care Coordination and Care Transitions
Element A :
Test Tracking and Follow-up
Element B :
Referral Tracking and Follow-up
Element C :
Coordinate Care Transitions
PCMH Standard 5
Element A: Test Tracking and Follow-up
Lab Tracking (Factors 1 & 3)
Overdue Results Flagging and Follow-up
Abnormal Results Alerting provider
Imaging Tracking (Factors 2 & 4)

Overdue Results Flagging and Follow-up
Abnormal Results Alerting Providers
Patient Notification of Results

Normal Results
Abnormal Results
PCMH Standard 5 contd

Element A: Test Tracking and Follow-up
Electronic Recording of Orders (labs & imaging)
Lab Orders electronically recorded in EHR
Imaging Orders electronically recorded in EHR
Electronically incorporates results into EHR (Must be able
to retrieve and review from your system)
55% of Lab Results as Structured Data Elements
Imaging Test Results (can be a scanned PDF of the
image)
Follows up regarding Newborn Screenings
Hearing
Blood-spot screening
PCMH Standard 5
Element B: Referral Tracking and
Follow-up
Considers available performance information on Specialists when
making referrals
Referral Tracking & Follow-up to obtain overdue reports
Integrates Behavioral Health Providers within the practice site
Has agreements with Specialists and Behavioral Health Providers
(Co-Management agreement documented in the medical record)
Gives specialist or consultant the clinical question, the required
timing and type of referral
PCMH Standard 5
Element B: Referral Tracking and
Follow-up Contd
Gives specialist or consultant the pertinent demographic
and clinical data, including test results and current care
plan
Asking patients about self-referrals
Has Capacity for Electronic Exchange of Key Clinical
Information
Electronic Summary of Care for more than 50% of
referrals
PCMH Standard 5
Element C: Coordinate with Facilities
and Manage Care Transitions
Proactively Identify patients with unplanned hospital admissions or ED visits
Share clinical information with admitting hospitals and ED Departments
Consistently obtains Discharge Summaries from hospitals or other facilities
Proactively contacts patients/families for appropriate follow-up care within an
appropriate period following a hospital admission or ED visit
Exchanges patient information with hospital during hospitalizations
Obtains proper consent for release of information and has a process for secure
exchange of information for coordination of care with community partners
Exchanges key clinical information with facilities and provides an electronic
summary of care record to another care facility for more than 50% of patient
transitions of care
Resources
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies

(Volume 7Care Coordination)
http://www.improvingchroniccare.org/index.php?p=Care_Coordination&s=326
Safety Net Medical Home Care Coordination Homepage
Improving Chronic Illness Care: Care Coordination Webpage
http://www.improvingchroniccare.org/downloads/care_coordination_toolkit_presentation.
ppt
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
QUESTIONS?

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NW AHEC Practice Transformation Series

Building Medical Homes Together

Care Coordination in the Medical

Primary Care Team

Five Key Elements of Care

Numerous participants are typically involved in care coordination;

Coordination is necessary when participants are dependent upon each

In order to manage all required patient care activities, participants rely on

Integration of care activities has the goal of facilitating appropriate delivery

Roles and Resources

Exchange of critical patientrelated information is

Care Coordination Goal (AIM)

The ultimate goal of Care

Why work on Care

Safety & quality

Reducing Care Fragmentation: Presentation on Coordinating Care

Are any of these

Specialists complain about the information you send with a referral.

You dont hear back from a specialist after a consultation.

A referral doesnt answer your question.

Your patient doesnt come back to see you after a consultation.

A specialist duplicates tests you have already performed.

You were unaware that your patient was hospitalized.

Patients Report Experiencing

What constitutes a high quality

Planned and managed to prevent harm to patients from

Based on scientific knowledge, and executed well to

Patients receive needed transitions and consultative

Responsive to patient and family needs and preferences.

Limited to necessary referrals, and avoids duplication of

The availability and quality of transitions and referrals

Reducing Care Fragmentation: Presentation on Coordinating Care

Group Health Research Institute

Three Levels of Patient

Clinical Follow-up Care

MacColl Institute for Healthcare Innovation, Group Health Research

#3 Build Relationships &

Identify, develop and maintain

Reducing Care Fragmentation: Presentation on Coordinating Care

Where might you start?

MacColl Institute for Healthcare Innovation

HOW DOES THIS RELATE TO

Test Tracking and Follow-up

Referral Tracking and Follow-up

Coordinate Care Transitions

Imaging Tracking (Factors 2 & 4)

Patient Notification of Results

PCMH Standard 5 contd

Reducing Care Fragmentation: Presentation on Coordinating Care

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies

Safety Net Medical Home Care Coordination Homepage

Improving Chronic Illness Care: Care Coordination Webpage

ARHQ Care Coordination Measures Atlas

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