Chapter 2 Elements of Highquality Programs Review Questions
Care coordination means dissimilar things to different people; no consensus definition has fully evolved. A recent systematic review identified over xl definitions of the term "care coordination."2 The systematic review authors combined the common elements from many definitions to develop i working definition for use in identifying reviews of interventions in the vicinity of care coordination and, every bit a outcome, developed a purposely wide definition: "Intendance coordination is the deliberate organization of patient care activities betwixt ii or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health intendance services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is oft managed by the exchange of information amongst participants responsible for different aspects of care." For some purposes, they noted that other definitions may be more advisable. This lack of consensus is perhaps not surprising given the many unlike participants involved in coordinating care.
In this section nosotros provide a visual definition (go to Figure ane) and scenarios to aid illustrate intendance coordination in the absence of a consensus definition. This visual definition may be helpful to some Atlas users, and less so to others. Several boosted illustrations of care coordination are presented in a contempo monograph on quality of cancer care.3
The central goal of intendance coordination is shown in the middle of the diagram. The colored circles represent some of the possible participants, settings, and data of import to intendance pathways and workflow. The blue ring that connects the colored circles is Care Coordination—namely, anything that bridges gaps (white spaces) along the care pathway (i.e., intendance coordination activities or broad approaches hypothesized to improve coordination of care). For a given patient at a given bespeak in time, the bridges or ring need to grade across the applicable circles, and through any gaps within a given circle, to deliver coordinated intendance.
Perspectives on Care Coordination
Successes and failures in care coordination will exist perceived (and may be measured) in different ways depending on the perspective: patient/family, health intendance professional(s), or organisation representative(due south). Consideration of views from these three potentially different perspectives is likely to exist important for measuring care coordination comprehensively.
Patient/Family unit Perspective. Care coordination is any action 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.4
Patients, their families, and other informal caregivers experience failures in coordination particularly at points of transition. Transitions may occur between health care entities (come across definition under "additional terms") and over time and are characterized by shifts in responsibility and information flow. Patients perceive failures in terms of unreasonable levels of attempt required on the part of themselves or their informal caregivers in social club to meet care needs during transitions amid health care entities.
Wellness Care Professional person(s) Perspective. Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care organization. Clinical coordination involves determining where to send the patient side by side (e.g., sequencing amidst specialists), what data well-nigh the patient is necessary to transfer among health care entities, and how accountability and responsibility is managed among all health care professionals (doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination addresses potential gaps in meeting patients' interrelated medical, social, developmental, behavioral, educational, informal support arrangement, and fiscal needs in order to reach optimal health, health, or finish-of-life outcomes, according to patient preferences.5
Wellness care professionals detect failures in coordination especially when the patient is directed to the "wrong" place in the health care system or has a poor health outcome every bit a result of poor handoffs or inadequate information exchanges. They also perceive failures in terms of unreasonable levels of effort required on their part in club to accomplish necessary levels of coordination during transitions amidst wellness care entities.
System Representative(due south) Perspective. Intendance coordination is the responsibility of whatever system of care (e.thousand., "answerable care organisation [ACO]") to deliberately integrate personnel, information, and other resources needed to carry out all required patient care activities between and amongst intendance participants (including the patient and breezy caregivers). The goal of care coordination is to facilitate the appropriate and efficient delivery of health care services both within and across systems.
Failures in coordination that affect the financial performance of the system will probable motivate corrective interventions. Organisation representatives will too perceive a failure in coordination when a patient experiences a clinically pregnant mishap that results from fragmentation of care.6
Additional Terms. Definitions for additional terms relating to care coordination are presented below.
Wellness intendance entities. Health care entities are discrete units of the health care organization that play distinct roles in delivery of care. The context and perspective will determine who precisely those units are. For case:
- From a patient and family perspective, entities are likely to be individual health care providers with whom the patient and family interact, such as nurses, physicians, and back up staff.
- From a wellness care professional perspective, entities may be private members of a piece of work group, such as nurses, physicians, and support staff in a item dispensary. Or they may be provider groups, such as a chief intendance exercise, specialty exercise, or urgent intendance clinic.
- From a system representative(due south) perspective, entities will likely exist groups of providers acting together as a unit, such as medical units in a hospital, hospitals as a whole, specialty clinics within an integrated system, or different clinical settings inside the wellness intendance system overall (i.e., ambulatory care, inpatient intendance, emergency care).
Points of transition. Transitions occur when information about or accountability/responsibleness for some aspect of a patient's care is transferred between two or more wellness care entities, or is maintained over time by 1 entity. Often information and responsibility are (or should be) transferred together.
It may be useful to remember about two broad categories of transitions:
- Transitions between entities of health care system. Information transfer and/or responsibleness shifts:
- Among members of 1 care team (receptionist, nurse, physician)
- Betwixt patient care teams
- Betwixt patients/informal caregivers and professional person caregivers
- Beyond settings (principal care, specialty care, inpatient, emergency department)
- Between health care organizations
- Transitions over fourth dimension. Information transfer and/or responsibility shifts:
- Betwixt episodes of care (i.e., initial visit and followup visit)
- Across lifespan (eastward.grand., pediatric developmental stages, women's changing reproductive cycle, geriatric care needs)
- Beyond trajectory of illness and changing levels of coordination need
Figure one. Intendance Coordination Ring
[D] Select for Text Clarification.
The key goal of care coordination is shown in the middle of the diagram. The colored circles represent some of the possible participants, settings, and information important to the intendance pathway and workflow. The blue ring connecting the colored circles is Care Coordination—namely, anything that bridges gaps (white spaces) along the care pathway (i.e., care coordination activities or wide approaches hypothesized to improve coordination of care. Get to Figure 2). Successes and failures in care coordination will be perceived (and may be measured) in different ways depending on the perspective: patient/family, health care professional(s), or system representative(due south).
Example Scenarios
The level of intendance coordination need will increase with greater system fragmentation (e.chiliad., wider gaps between circles), greater clinical complexity (eastward.g., greater number of circles on ring), and decreased patient capacity for participating effectively in coordinating one'southward own intendance, as illustrated by the following scenarios. The level of need is non fixed in fourth dimension, nor by patient. Cess of level of care coordination is likely of import to tailor interventions accordingly and to evaluate their effectiveness.
Scenario 1. Mrs. Jones is a healthy 55-twelvemonth-erstwhile woman. She visits her master intendance provider, Dr. I. Care, once a twelvemonth for a routine concrete. Dr. Care practices in a master care clinic with an electronic medical record (EMR) organization and on-site laboratory and radiology services. At Mrs. Jones' annual physical, Dr. Care ordered several claret tests to evaluate her cholesterol and triglyceride levels. Mrs. Jones also mentioned that she is having lingering pain in her talocrural joint after a previous sprain. Dr. Care ordered an 10-ray. Afterward receiving the blood test results via the electronic medical record organization, Dr. Care sees that Mrs. Jones' cholesterol is high and prescribes a medication. She submits the prescription direct to the pharmacy via a link from the EMR. She receives electronic notification that the x-ray does not show any fracture. She calls Mrs. Jones to refer her to a nearby physical therapy do. Mrs. Jones picks upwards her medication from the pharmacy and calls the physical therapist to schedule an appointment.
Scenario 1. Visual
Complication: Low
Fragmentation: Depression
Patient Capacity: Loftier
Care Coordination Need: Minimal
[D] Select for Text Description.
Scenario 2. Mr. Andrews is a 70-year-former human with congestive heart failure and diabetes. He uses a cane when walking and recently has had some balmy memory problems. His primary care physician, Dr. Busy, is part of a small group medico practice focused on primary care. The main care clinic includes a laboratory, but they refer their radiology tests to a nearby radiology eye. Mr. Andrews too sees Dr. Kidney, a nephrologist, and Dr. Love, a cardiologist. Both specialists are part of a specialty group practice that is non affiliated with Dr. Busy's clinic. Their specialty practice includes an on-site laboratory, radiology clinic, and pharmacy. Mr. Andrews has prescriptions filled at the specialty dispensary chemist's after his appointments with Drs. Kidney and Dear and picks upward medications prescribed by Dr. Busy at a pharmacy near his home. Mr. Andrews has a daughter who lives nearby but works full time. Because he has trouble getting to the grocery store to do his shopping, he receives meals at his domicile five days a calendar week through a meals-on-wheels senior support service. His daughter has hired a caregiver to help Mr. Andrews with household tasks for ii hours 3 days a week.
During a contempo meal commitment, 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 center failure exacerbation and was admitted. During his initial evaluation, the albeit medico asked Mr. Andrews about which medications he was taking, merely the patient could non think what they were or the doses. The physician on the hospital team contacted Dr. Busy, who provided a medical history and full general listing of medications. Dr. Busy noted that Mr. Andrews may have had dosing changes subsequently a recent appointment with Dr. Honey. In addition, Dr. Decorated noted that Mr. Andrews may be missing medication doses because of his forgetfulness. He provided the hospital team with contact information for Drs. Dear and Kidney. He also asked that a record of Mr. Andrews' hospital stay be sent to his office upon his belch.
Mr. Andrews was discharged from the hospital one week subsequently. Before going home, the nurse reviewed of import data with him and his daughter, who was taking him home. They went over several new prescriptions and details of a low-salt diet. She told him to schedule a followup appointment with his primary intendance physician inside 2 days and to see his cardiologist in the adjacent 2 weeks. Mr. Andrews was very tired so his daughter picked upwards the prescriptions from a pharmacy near the hospital, rather than the 1 Mr. Andrews usually uses.
Scenario 2. Visual
Complication: High
Fragmentation: Moderate
Patient Capacity: Low
Intendance Coordination Need: Extensive
2 McDonald KM, Sundaram V, Bravata DM,et al. Care coordination. In: Shojania KG, McDonald KM, Wachter RM, and Owens DK, eds. Endmost the quality gap: A critical analysis of quality improvement strategies. Technical Review 9 (Prepared past Stanford-UCSF Evidence-Based Practise Center under contract No. 290-02-0017). Vol. 7. Rockville, MD: Bureau for Healthcare Inquiry and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7.
3 Taplin SH, Rodgers AB. Toward improving the quality of cancer care: Addressing the interfaces of primary and oncology-related subspecialty care. J Natl Cancer Inst Monogr 2010;xl:three-10.
iv Adapted from information published by the National Quality Forum.
5 Adjusted from information published in: Antonelli RC, McAllister JW, Popp J. Making care coordination a critical component of the pediatric healthcare system: A multidisciplinary framework. New York: The Commonwealth Fund; 2009.
6 Adapted from information published in: McDonald KM, Sundaram V, Bravata DM, et al. Care coordination. In: Shojania KG, McDonald KM, Wachter RM, and Owens DK, eds. Closing the quality gap: A disquisitional analysis of quality improvement strategies. Technical Review ix (Prepared past Stanford-UCSF Evidence-Based Practice Middle under contract No. 290-02-0017). Rockville, Dr.: Agency for Healthcare Enquiry and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7.
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