Chapter 1: Overview of Care Coordination

Care Coordination and Interoperable Health IT Systems

Overview of Care Coordination

Health IT Workforce Curriculum

Version 4.0/Spring 2016

This material (Comp 22 Unit 1) was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006. 

This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit 
http://creativecommons.org/licenses/by-nc-sa/4.0/.

Welcome to Care Coordination and Interoperable Health IT Systems, Overview of 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 chapter, you will become better navigators to better guide and coordinate care for patients traveling through the complex and often frightening healthcare maze. 

Overview of Care Coordination Part A

The Objectives for Chapter 1, Overview of Care Coordination, Part A are to: 

• Define care coordination effectiveness  

• And 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.

As defined by 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.

Care coordination involves:

• Deliberately organizing patient care activities

• Sharing information among all individuals involved in the patient’s care

• Using information to deliver safe, appropriate, and effective care

• Accounting for the patient’s needs and preferences before making decisions

• Preparing for care transitions

We can begin with a case example of Coordinated Care from the Association for Healthcare Quality and Research’s Care Coordination Measures 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. Andrew’s Primary Care Physician (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 his discharge.

Before releasing Mr. Andrews is given instructions and his daughter is informed of next steps, so she too can be involved in Mr. Andrew’s 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 health care needs when and where the patient needs and desires care. Care coordination can ensure multidisciplinary health teams’ optimum collaboration with communication of pertinent health information over time between the health care teams disciplines’ 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 health care systems. 

The Safety Net Medical Home defines Care coordination as “[beginning] with the thoughtful identification of key services 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 health care services.”

A team-based approach to care coordination ensures that responsibility and accountability for the patient’s care is shared equitably among all participants caring for the patient. Care teams may be comprised of a range of members from different care settings and disciplines, including all of those you see listed here and more.  Care teams should always include the patient and their family.

As Christine Bechtel from the National Partnership for Women and Children expressed, patients “just want doctors to talk to each other.”

The Health Insurance Portability and Accountability Act, more commonly known as HIPAA, the federal law often referred to when discussing requirements for maintaining the privacy and security of protected health information or PHI.  PHI is individually identified health information related to the care of a patient. Administered by the Department of Health and Human Services Office of Civil Rights, the Security Rule provides the technical specifications for management of PHI maintained in electronic systems; while the Privacy Rule provides the regulations pertaining to all PHI, whether in paper or electronic systems.

What HIPAA does not do is prevent providers and others from sharing individually identified health information or PHI to coordinate services for patients.  Care coordination facilitated through the 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 health care 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 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.

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 Medicaid. 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 family’s 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 afterschool 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 capital 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 health care outcomes, and reduces costs associated with health care fragmentation, which can lead to under- and overutilization 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 

• Making all whole-person shared-decisions and goals 

Care coordination is essential for delivering whole-person care because this relatively new model requires organizations that have historically not worked together to collaborate.  For example, a teen parent may need transportation to both appointments and a parenting education class offered by the community college.

In another example, we know that substandard housing with mold or insect infestations can result in health problems.  Collecting that data and incorporating it into the information used for care decision-making is paramount for whole-person care.

The American College of Physician’s defines the patient-centered medical home as a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand. When used, PCMHs function use health information technology extensively to be the repository holding information for measurement, target health goal setting and shared decision making teams using whole-person health information. This picture illustrates how the patient is at the center of the PCMH team and support efforts.

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 antihypertensive drug doses until her depression was under better control, and referred her to the mental health center.  

Ms. H’s Primary Care Physician had previously met with the clinical director of the mental health center. The center’s physiatrist was shown how to log in to and use the practice’s 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 EMTs 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.

Information used in care coordination can come from many different sources, including

• Demographics – This information might include address or education level or race/ethnicity

• Patient-generated health information is becoming more and more common from the Internet of Things and may include data such as weight, blood pressure, heart rate or steps taken each day

• Clinical documentation notes – commonly come from visits or other patient interactions with caregivers.

• Medication management information –comes from medication records, but may also come from pharmacies.

• Care plans – are documents from the care team that include the patient and describe the expected actions to be taken by all 

There are many other sources of information.

Health information technology in it’s many different forms can be used to both collect these different data types and then turn them into information for use in decision-making.

Care Coordination Systems Essentials include: 

• The use of patient health information (PHI) and technology systems to support care coordination that isstandard and consistent. 

• Health information technology (HIT) systems capabilities should be well aligned with the clinicians’ 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 requires collaboration.  This may include meeting with stakeholders to develop an understanding of roles and responsibilities to guide 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, care givers may need to develop a standardized approach to care supporting the needed collaboration, coordination and communication.

This concludes Chapter 1, Part A, What is Care Coordination? of Section 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. 

Overview of Care Coordination Part B

Welcome to Care Coordination and Interoperable Health IT Systems, Overview of Care Coordination.  This is Part B - Care Coordination Models.

Thank you for taking your valuable time to invest in learning what it means to coordinate care. As you view and learn from this chapter you will become better navigators so you can truly be better guides to coordinate care with your patients traveling through the complex and often frightening healthcare maze. 

The Objectives for this chapter, Overview of Care Coordination, Part B, are to: 

• Discuss various models of Care Coordination and compare care coordination roles and responsibilities in the post-Affordable Care Act models of care across the care continuum.

There are many different models of care coordination, along with various means of paying for the coordinated care.  In addition to all of the different methods listed here, those interested are encouraged to go to the CMS website to explore new models ranging from Accountable Care Organizations or ACOs to the Oncology Care Model to Comprehensive Primary Care Plus to Strong Start for Mothers and Newborns and many more.  This lecture will briefly review patient-centered medical home, accountable care organization, Comprehensive Primary Care Plus, Care Transitions, Guided Care, Transitional Care Advanced Practice Nursing model, Community-based Care Transitions, and Bridges to Health.

Almost all of the current coordinated care models are focused on developing partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. 

Care coordination models depend on multidisciplinary collaborative partnership relationships where there is mindful and purposeful clinician-patient communication based on trust, respect, and shared decision-making to place the patient and family at the center of care. Culturally sensitive care coordination fosters the continuous relationship with a personal physician coordinating care for both wellness and illness for whole person care. 

PCMH Care coordination helps patients choose specialists and obtain medical tests results to share to avoid retesting when necessary. It also informs specialists of any necessary accommodations for the patient’s needs and helps access other needed providers or health services (including providers or health services not readily available in the patient’s community- including rural or underserved areas).

CMS Accountable Care Organizations (ACOs) are generally voluntary organization of multiple health care providers who are focused on caring for the chronically ill. They are trying to provide the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors.

Comprehensive care primary care plus is an advanced primary care medical home model that focusses on access and continuity as well as managing the care. It intends to be comprehensive and coordinated with significant patient and caregiver engagement, utilizing principles from planned care and population healthmanagement.

The Care Transitions model of care was developed by Eric Coleman and is intended to address the problems of patients who are discharged from the hospital and going home. It utilizes advanced practice nurses who are trained as coaches and assist the patients and their families in developing self-care skills.

The John Hopkins Guided Care Model is generally led by a registered nurse who both assesses and plans the care. The team then provides the care for chronically ill patients that is coordinated, patient-centered and cost effective.

Mary Naylor from the University of Pennsylvania developed the coordination of care advanced-practice nursing visits in hospital, home, and by telephone as interventions for older adults hospitalized for chronic health conditions.

The Community-Based Care Transitions Program promotes seamless transitions from acute hospital care to post-acute care back to the home community, skilled nursing care or home health care providing a model of best practice tools through a CMS supported Care Transitions Quality Improvement Organization Support Center (QIOSC) to engage, provide support and help the entire community to help build better health care coordination strategies, coalition charters, data analytic tools, and information on mapping and network analysis. 

The Bridges to Health model offers a way to think about developing programs for segments of the population that meet patients’ needs for coordinated, integrated care delivery programs and services that meet the needs of each of the populations outlined in the model. When these programs are integrated, they should improve the quality and efficiency of care coordination for the entire population.

Most care coordination models are reliant upon well-designed information systems, including secured health information repositories that allow providers to share whole person information. This is necessary for effective measurement of the care delivery models as well as establishing target goals for shared decision-making.

Care coordination population health and chronic disease management systems allow patient population conditions stratification and identification of high acuity care needs. Systems evidence-based guidelines outline appropriate care when needed.

Care coordination systems track test results, share information with patients, and ensure that patients receive appropriate follow-up care and help in understanding results and treatment recommendations. These systems also ensure smooth transitions by assisting patients and families as the patient moves from one care setting to another such as from hospital to home.

Care coordination information systems also help prevent errors when multiple clinicians, hospitals, or other providers are caring for the same patient, using tools such as medication reconciliation and shared medical records. It has systems in place to help patients with health insurance eligibility, costs, coverage and appeals or to refer patients to sources that can be of assistance. In addition, systems can identify and address barriers or needs due to individual’s social determinants of health.

This concludes Part B - Care Coordination Models of Chapter 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.There are various post-Affordable Care Act models of care coordination across the care continuum.

Overview of Care Coordination Part C

Welcome to Care Coordination and Interoperable Health IT Systems, Overview of Care Coordination.  This is Lecture c - Long Term 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 so you can truly be better guides to coordinate care with your patients traveling through the complex and often frightening healthcare maze. 

The Objectives for this chapter, Overview of Care Coordination, Part C are to:

• Discuss Specialty care coordination;

• Discuss Long term care/post-acute care and

• Identify stakeholders in care coordination.

First we will discuss CMS Accountable Care Organizations (ACOs):

• These organizations are voluntary organizations of multiple health care providers.

• Focused on chronically ill patients and provide the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors.

Some of the ACO Programs at CMS are:

• Medicare Shared Savings Program – which is fee-for-service

• ACO Investment Model – which is testing pre-paid savings in rural and underserved areas

• The Comprehensive ESRD Care – focusing on dialysis 

• The Next Generation ACO Model – for those ACOs that already have experience and

• The Pioneer ACO Model – for organizations experienced in care coordination.

ACO Goals are to prepare for and implement new reimbursement methods measuring outcomes across the care continuum. They also hope to align diverse stakeholders in a geographic area and implement planned and coordinated care processes specialized for chronic conditions and preventative care. 

Accountable Care Goals include: 

• Developing a clinical integration system to align practices and providers around systems thinking approaches to meet patient-centered organizational goals;

• Understanding, planning for and adopting risk-stratified care management aligned with care coordination and using health information technology to manage populations utilization needs for specialists care in order to better provide accountable care.

Home-Based Chronic Care Model and the Integrated Care Model (ICM) by the Sutter Center for Integrated Care includes:

• Community-based care delivered in a home health setting; 

• It may also include Custodial Care; the Old-fashioned Medical House Calls;

• Setting up a Hospital at Home as well as Palliative, Hospice and Advanced Illness care. 

Skilled nursing home facilities, rehabilitation facilities, home health and hospice are examples of the long term post-acute and chronic health condition care settings where care is ordered and referred by the primary care physician team leaders and care coordination expands to multidisciplinary teams.  Care teams are responsible for ongoing care coordination and securely maintaining and sharing pertinent patient health information. 

Shared plans of care are developed and designed to meet all of the individual patient’s unique care needs to include the right combination of prescribed post-acute services that may include skilled nursing, rehabilitation, therapies, nutrition, counseling and household support throughout the life span. 

Care coordination includes periodic assessment and review of needs and abilities on an ongoing basis, keeping care teams informed about changes in patient conditions, addressing needs related to social determinants of health, sharing patient information with care teams and collaborating for self-care management with the engaged and activated patient and family.

The Care Coordination from facilities to home model leads to decreased length of hospital and facilities stay and a decrease in unnecessary readmissions. It has increased interest in how care coordination for transition from hospital to home can benefit patients and families. Hospitalized patients can be discharged to home to rely on physician ordered and coordinated care through home services which may include end of life hospice, or palliative care and also any type of appropriate home skilled nursing care or simple attendant household assistance in the home. 

Patient and caregiver interviews reveal that satisfaction with home health care and hospice or palliative care services have proven by research to be positively related to the receipt of needed care, information from the home care staff about medications, equipment/supplies, and self-care. 

Caregiver burden was inversely related to care coordination for receiving information which may include education and information delivered through technology systems from integrated health care organizations. Recommendations for improving care coordination in the transition from hospital to home at the near end of life includes providing more information, more reassurance and emotional support, and more household assistance. 

Stakeholder perceptions and valued attributes of care coordination and care delivery experiences that relate to care coordination, include sharing health information through improved technology, participating as expanded team members of the patient-centered medical home team, and sharing decision making in agreed upon physician orders for patient care prescribed by the ordering and referring primary care team physician. 

These valued care coordination attributes include data-driven management for coordinating care through measured care assessment, care planning, monitoring, reviewing, providing uninterrupted care services, continuity, trusting-partner relationships, and collaborative shared-decision making.

Stakeholders in the Care Coordination process include:

• Patients and families, entire communities as well as Federal, state and municipal governments. 
• Consumers and consumer groups are also involved as well as Advocacy and public policy groups. 
• Health care reimbursement entities and organizations such as Health plans, Government plans. Employers And other Purchasers are also involved.

Other Stakeholders in Care Coordination include:

• Patient Centered Medical Home care teams and care coordinators

• Home caregivers

• Nursing and home attendant service providers

• Care managers

• Physicians 

• The Medical neighborhood

• Health information technology systems groups

• As well as Telehealth, telemedicine and virtual care groups

Patients and families: Perhaps the most invested stakeholders in care coordination include the patients and families who traditionally have passionately performed most of the care coordination for a loved one although they often have accomplished the care coordination with no formal training in health care.

Entities and health care organization stakeholders responsible for reimbursement of health care support shared savings models, value-based models, and models where risk-adjusted comprehensive primary care payments from public and private payers as well as employer groups strategically promote care coordination as a quality outcomes and utilization improvement measure. 

Care coordination is a stakeholder priority that will focus on controlling and reducing the total cost of health care for an individual or population because increasing appropriate navigation across care transitions has proven to decrease costs and improve outcomes. 

Advocates and policymakers:

Regulatory policymakers and advocates in the public, government and private sectors are among the many stakeholders in care coordination addressing aspects of the health system that can eliminate barriers to better care coordination. 

Policymakers, agencies and government leaders at the state and federal levels drive health system regulatory reform based on information and data metrics from programs that incorporate key features of care coordination integrated into health care reform models such as patient-centered medical home and neighborhood, accountable care organizations, health information technology systems and payment reform services and programs.

For Employers and purchasers redesigning benefits programs to incorporate health care coordination and systems technology features into innovative payment models that work to share best practices and resources based on successful models, including workplace wellness initiatives, increasing prevention programs and benefit structures – each are tied to stakeholder positions for improved health care coordination and systems technology.

This concludes Lecture c, Long-term Care Coordination of Unit 1: Overview to Care Coordination.

To summarize:

Care Coordination requires collaboration and communication between the primary care physician team leader, care team and the patient.

In Long term care, teams are responsible for ongoing care coordination and securely maintaining and sharing pertinent patient health information about patients.

There are variety of stakeholders in Care Coordination, the most important being the patients.

To summarize the unit Overview to Care Coordination:

Care Coordination requires collaboration and communication between the primary care physician team leader, care team and the patient.

There are various post-Affordable Care Act models of care coordination across the care continuum.

Patients are the most important stakeholders in Care Coordination.