Care Coordination Model Research Articles

Care Coordination Models and Tools-Systematic Review and Key Informant Interviews.

Care coordination (CC) interventions involve systematic strategies to address fragmentation and enhance continuity of care. However, it remains unclear whether CC can sufficiently address patient needs and improve outcomes. We searched MEDLINE, CINAHL, Embase, Cochrane Database of Systematic Reviews, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program, from inception to September 2019. Two individuals reviewed eligibility and rated quality using modified AMSTAR 2. Eligible systematic reviews (SR) examined diverse CC interventions for community-dwelling adults with ambulatory care sensitive conditions and/or at higher risk for acute care. From eligible SR and relevant included primary studies, we abstracted the following: study and intervention characteristics; target population(s); effects on hospitalizations, emergency department (ED) visits, and/or patient experience; setting characteristics; and tools and approaches used. We also conducted semi-structured interviews with individuals who implemented CC interventions. Of 2324 unique citations, 16 SR were eligible; 14 examined case management or transitional care interventions; and 2 evaluated intensive primary care models. Two SR highlighted selection for specific risk factors as important for effectiveness; one of these also indicated high intensity (e.g., more patient contacts) and/or multidisciplinary plans were key. Most SR found inconsistent effects on reducing hospitalizations or ED visits; few reported on patient experience. Effective interventions were implemented in multiple settings, including rural community hospitals, academic medical centers (in urban settings), and public hospitals serving largely poor, uninsured populations. Primary studies reported variable approaches to improve patient-provider communication, including health coaching and role-playing. SR, primary studies, and key informant interviews did not identify tools for measuring patient trust or care team integration. Sustainability of CC interventions varied and some were adapted over time. CC interventions have inconsistent effects on reducing hospitalizations and ED visits. Future work should address how they should be adapted to different healthcare settings and which tools or approaches are most helpful for implementation. PROSPERO #CRD42020156359.

Characterizing Low-Risk Breast and Gynecological Cancer Patients for Transition into an Oncology/Primary Care Coordinated Care Model: Findings from a Survey of Diverse Survivors in a Rural U.S. State.

Simple SummaryWe conducted a survey to identify the key aspects that influence cancer care for racial/ethnic and geographically diverse low-risk breast and gynecologic cancer patients. New Mexico is a large state with many ethnic and racially diverse communities who reside in rural areas. Data obtained through our New Mexico Tumor Registry show that these patients often have different and worse cancer health outcomes. To learn more about how to improve their care, we surveyed patients regarding their access to primary care (PC); compliance with screening recommendations; treatment for conditions other than cancer (e.g., diabetes, obesity, heart problems, etc.); difficulties attending their clinic visits; and whether or not they received information about their survivorship care in the form of a survivorship care document (SCD). We found that the majority of the 150 patients surveyed reported having a Primary Care Provider (PCP). Many had health complications other than cancer, those who resided in rural areas had more difficulties getting to their cancer follow-up appointments, and nearly half had not received SCDs. We used these survey results to develop an oncology/PCP care coordination intervention to improve the oncology and cancer survivorship care for those who were at low risk of recurrence.We conducted a survey to characterize the key attributes of racial/ethnic and geographically diverse low-risk breast and gynecologic cancer patients. We collected data regarding patients’ access to primary care (PC); compliance with screening recommendations; treatment for comorbidities; logistical barriers to clinic visits; and receipt of survivorship care documentation (SCD). Survey findings informed the development of an oncology/Primary Care Provider (PCP) care coordination intervention to improve care. We distributed a cross-sectional survey among a convenience sample of 150 cancer survivors. Responses were calculated using descriptive statistics and compared based on the distance participants traveled to their appointments at the cancer center (≤30 vs. >30 miles). Of the 150 respondents, 35% traveled >30 miles for follow-up care and 78% reported having one or more comorbid condition(s). PC utilization was high: 88% reported having a PCP, and 91% indicated ≤1 yearly follow-up visit. Participants traveling >30 miles reported higher rates of logistical challenges associated with cancer center visits compared to those traveling ≤30 miles. Nearly half of respondents (46%) had not received SCD. In conclusion, survey studies such as these allow for the systematic assessment of survivor behaviors and care utilization patterns to inform the development of care coordination interventions for diverse, low-risk cancer patients.

Care coordination as a collaborative element of recovery oriented services for persons with severe mental illness.

To propose a model where care coordination can form part of recovery oriented care when it is included as a collaborative element of services for persons with severe mental illness. A recovery-oriented service requires more than clinical interventions. It also needs to address social determinants and be individualised or person centred. Multiple health and community services need to be involved. A care coordination model is capable of addressing multiple needs. It gives the client the first and foremost voice. It facilitates intersectoral collaboration, reduces the burden on clinical mental health services and is supported by mental health and community service personnel.

Redesigning the Pre-Admission Testing Process in a Specialized Children's Hospital, Moving Towards a Model of Care Coordination

<h3>Background Information</h3> We serve a patient population which includes many complex pediatric and young adult patients, who often present for surgery with an extensive list of comorbidities. Our pre-admission testing process was deemed inefficient, task focused vs. process focused. Multiple nurses could potentially touch a chart, leading to several hand offs, with no way of determining patient acuity. Our team felt overwhelmed and understaffed. <h3>Objectives of the Project</h3> Our goal with our workflow redesign was to streamline our processes, thereby increasing efficiency in the department, minimizing patient/chart handoffs and assuring a safe surgical experience for our patients. <h3>Process of Implementation</h3> Our core PreAdmit Testing team met and mapped out our current processes. This clearly illustrated the complexity of our system and the redundancies that existed. We also identified areas within our system that worked well. Four members of our team formed a task force to redesign the workflow, moving towards a model of care coordination. A point based acuity scale was developed, classifying patients as "red", "yellow" or "green", depending on number of points. Points reflect their comorbidities, complex psychosocial situations, multiple medications or required medication weans and labs and/or imaging procedures ordered in conjunction with surgical procedures. Any patient classified as "red" is assigned to one core Pre-Admit Testing nurse, who is responsible for coordinating all aspects of pre-op preparation, thus reducing handoffs. Care for "yellow" patients is also coordinated by core Pre-Admit testing staff. Patients classified as "green" can be delegated to nurses floating to the Pre-Admit office to prepare the chart and complete the pre-op phone call with the family. We are able to monitor productivity via EMR reports. <h3>Statement of Successful Practice</h3> PreAdmit Testing for our most complex patients has been streamlined, thus minimizing hand offs and assuring comprehensive preparation for surgery. Staff feedback confirmed that efficiency in the PreAdmit Testing office has improved as well as team satisfaction. Anesthesia colleagues have also reported satisfaction with our processes. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> In the future, the patient's acuity score will be available in the EMR to help guide pre-op as well as post-op care. It is our belief that streamlining our processes will improve patient safety.

Implementation of the Wolverine Mental Health Program, Part 2: Implementation Phase

To enhance mental health care for youth in a midwestern residential treatment facility, Wolverine Human Services partnered with the Beck Institute (an intermediary) and an implementation research team to implement cognitive-behavioral therapy (CBT). CBT has strong evidence supporting effectiveness for treating youth internalizing and externalizing problems, but it is a complex psychosocial intervention that demands a thoughtful implementation approach. This study outlines the implementation phase (2.5 years) of a 5-year collaborative effort. The implementation phase focused on (a) adapting CBT to fit the complex youth needs and the roles of the multidisciplinary team members resulting in a new comprehensive and coordinated care model, and (b) the strategies utilized to support its competent integration by all team members. Six blended implementation strategies were deployed in this phase: forging implementation teams, installing progress monitoring, adapting CBT, training, providing supervision and consultation, and training the trainers. A components-based approach to CBT yielded six core skills: active listening, problem solving, mood monitoring and intervention mapping, activity scheduling, distress tolerance, and cognitive restructuring. By the end of this phase, all staff had robust exposure to and experience with the adapted form of CBT. The work of our academic–community partnership has both research and clinical implications, with respect to integrating an adapted version of CBT for residential environments (CBT-RE).

Pregnancy and birth in the United States during the COVID-19 pandemic: The views of doulas.

BackgroundMuch of the emerging research on the effects of SARS‐CoV‐2 disease (COVID‐19) on pregnant people and their infants has been clinical, devoting little attention to how the pandemic has affected families navigating pregnancy and birth. This study examined the perspectives of doulas, or nonclinical labor support professionals, on how pregnancy and birth experiences and maternal health care delivery systems changed in the early weeks of the COVID‐19 pandemic.MethodsSemi‐structured interviews using open‐ended questions were conducted over the phone with 15 birth doulas. Doulas were invited to participate because of their close relationships with pregnant and birthing people and the comprehensive support they offer. The interview transcripts were analyzed inductively.ResultsDoulas’ clients faced three predominant COVID‐19‐related pregnancy and birth challenges: (a) fear of exposure; (b) limited access to their expected support systems; and (c) uncertainties surrounding hospital restrictions on labor and birth. Doulas responded creatively to help their clients confront these challenges. Participants expressed various criticisms of how maternal health care systems handled the emerging crisis, argued that COVID‐19 exposed preexisting weaknesses in US maternity care, and called for a coordinated care model involving doulas.DiscussionDoulas' close relationships with pregnant people enabled them to be an important source of support during the COVID‐19 pandemic. Added to the larger body of work on the impacts of doula care, this study supports widespread calls for universally integrating doulas into maternity care systems as a targeted strategy to better support pregnant and birthing people in both crisis and noncrisis situations.

An Optimal Care Coordination Model for Medicaid Patients with Lung Cancer: Finalization of the Model and Implications for Clinical Practice in the United States

An Optimal Care Coordination Model for Medicaid Patients with Lung Cancer: Finalization of the Model and Implications for Clinical Practice in the United States

Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care.

Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care.

Identification and Treatment of Addiction in Medicaid Health Homes.

Coordinated care models, such as the Medicaid health home, may be well positioned to identify and address addiction, yet little is known about the strategies health home plans use to identify and treat this condition. This study examined state requirements of active Medicaid health home plans. Content analyses of all 35 active Medicaid health home plans were conducted to identify state requirements related to enrollment eligibility; provision of addiction screening, treatment, and prevention services; inclusion of addiction treatment professionals within the health home provider care team; and outcomes monitoring. Apart from health homes specifically focused on addiction, few states require health home plans to screen (44% of primary care-based and 33% of psychiatric health homes), treat (0% and 13%, respectively), and monitor treatment services for addiction (25% and 13%, respectively). Limited screening and treatment of addiction within health homes may limit the model's effectiveness in improving overall health.

Measuring patient experiences of person-centred care: Translation, cultural adaption and qualitative evaluation of item candidates for use in England and Sweden.

To facilitate change for person-centred care, there is a need to invest in measures to assess if and how healthcare systems are delivering care based on the principles of person-centred care. This paper describes the first phase in developing an item bank to measure patients' experiences of person-centred care. The aim was to translate, culturally adapt and evaluate candidate items to measure person-centred care from the patient's perspective. The Centre for person-centred care at Gothenburg university and the UK Person-centred and coordinated care model informed our conceptual framework. The initial pool of item candidates originated from a previous systematic review where 855 items were identified. In this study, a mixed method design was used involving persons with experience as patients, caregivers, healthcare professionals and researchers in person-centred care or questionnaire design (n=84). The item analysis included two validation rounds using web questionnaires, a focus group and cognitive interviews. From the initial pool, 155 items covering core domains and subdomains of person-centred and coordinated care were selected for translation and qualitative item analysis. After translation, 44 items were excluded (duplicates). After the first validation round, 21 items were rephrased and 35 were excluded (due to low ratings, lack of comprehensibility, were duplicates or too specifically phrased). To reflect the ethical basis of person-centred care, rewordings were also made to encompass the patient as an active partner in care and where communication and information goes two-ways and care is co-created. After the second round, 11 items were rephrased and 25 items were excluded (for being redundant/repetitive). Six new items were added (covering access to care, patient capabilities, mental well-being and identifying goals). We have developed a first set of 57 items to proceed towards developing an item bank to measure the patient experiences of person-centred care.

An Optimal Care Coordination Model for Medicaid Patients with Lung Cancer: Results from Beta Model Testing

Lung cancer continues to be the leading cause of cancer mortality in the United States, with an estimated 142,670 deaths in 2019.1 Gaps in the quality of care remain in many areas, contributing to ...

A Man Named Peter: Living in Long-Term Care as a Younger Adult

A Man Named Peter: Living in Long-Term Care as a Younger Adult

Prostate cancer survivorship care: if not now, when?

Prostate cancer is the most common cancer diagnosed in Australian men (excluding non-melanoma skin cancer) and it is estimated that there are over 220,000 Australian men living with a diagnosis of prostate cancer [1]. Survival for men with prostate cancer is excellent in countries that have accessible screening and treatment services, and in Australia five-year relative survival is over 95% [1]. High incidence coupled with improving long term survival leads to a corresponding high prevalence rate and high community disease burden. Many men with prostate cancer experience long term decrements in their mental and physical quality of life, overall they have a greater suicide risk that their non-cancer peers, and unmet supportive care needs are pervasive [2].

THE IMPLEMENTATION OF CARE COORDINATION MODEL TOWARD DELIVERY OF QUALITY CARE IN PRIVATE HOSPITAL OUTPATIENT SETTING

&lt;p&gt;Health care services in the private hospitals are required to deliver quality care to stay competitive in the business. In line with the advancement of hospital facilities and the raise of patient needs for complex care, the care coordination is inevitable to ensure the delivery quality of care. The purpose of this study is to test and analyze the care coordination model toward delivery of quality care in the private hospital outpatient setting. This research model was empirically tested on outpatient clinic at one of the leading hospitals in Indonesia. The data was analyzed by PLS-SEM method, whereas respondent obtained by purposive sampling technique. The result of structural model, shown moderate to strong prediction accuracy with large predictive relevance indicate and acceptable model. The result demonstrated that all of care coordination paths lead to the delivery of quality care has significant positive effect, except for facilitate transitions and accountability to communication and information transfer. However, facilitate transitions and accountability has significant positive effect through IT-enabled care coordination and through interprofessional teamwork and consistency. Therefore, it could be concluded that all variables have contribution to the care coordination in the outpatient, respectively. The strongest direct effect to care quality perception is found from communication and information transfer, while the strongest indirect effect is from physical infrastructure and facilities which mediating by IT-enabled care coordination and further communication and information transfer. There are managerial implications that could give suggestions for hospital managers to improve care coordination process in hospital outpatient services.&lt;/p&gt;

A Systematic Review of Primary Care and Payment Models on Emergency Department Use in Patients Classified as High Need, High Cost

IntroductionReducing costly and harmful ED use by patients classified as high need, high cost is a priority across health care systems. The purpose of this systematic review was to evaluate the impact of various primary care and payment models on ED use and overall costs in patients classified as high need, high cost. MethodsUsing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search was performed from January 2000 to March 2020 in 3 databases. Two reviewers independently appraised articles for quality. Studies were eligible if they evaluated models implemented in the primary care setting and in patients classified as high need, high cost in the United States. Outcomes included all-cause and preventable ED use and overall health care costs. ResultsIn the 21 articles included, 4 models were evaluated: care coordination (n = 8), care management (n = 7), intensive primary care (n = 4), and alternative payment models (n = 2). Statistically significant reductions in all-cause ED use were reported in 10 studies through care coordination, alternative payment models, and intensive primary care. Significant reductions in overall costs were reported in 5 studies, and 1 reported a significant increase. Care management and care coordination models had mixed effects on ED use and overall costs. DiscussionStudies that significantly reduced ED use had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Identifying primary care models that effectively enhance access to care and improve ongoing chronic disease management is imperative to reduce costly and harmful ED use in patients classified as high need, high cost.

An Optimal Care Coordination Model for Medicaid Patients with Lung Cancer: Rationale, Development, and Design

Patient-centered care that is accessible, affordable, evidence based, and well coordinated is integral to high-quality cancer care delivery.1 Medicaid and other socioeconomically disadvantaged pati...

A model of care coordination for patients with complex health and social care needs - what is best?

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Reducing Tobacco Use in Oregon Through Multisector Collaboration: Aligning Medicaid and Public Health Programs.

IntroductionTobacco use is the leading cause of preventable death and disease in the United States. Oregon’s coordinated care model for Medicaid provides an opportunity to consider novel ways to reduce tobacco use.Purpose and ObjectivesWe sought to evaluate the changes in tobacco cessation benefits, patient access to cessation interventions, and cigarette smoking prevalence before and after introduction of the statewide Coordinated Care Organization (CCO) cigarette smoking incentive metric for Medicaid members.Intervention ApproachMedicaid and public health collaborated to develop a novel population-level opportunity to reduce tobacco use. In 2016, an incentive metric for cigarette smoking was incorporated into Oregon’s CCO Quality Incentive Program, which holds Oregon’s CCOs accountable for providing comprehensive cessation benefits and for reducing tobacco use prevalence among members.Evaluation MethodsWe evaluated the changes in tobacco cessation benefits, patient–provider discussions of smoking cessation, and cigarette smoking prevalence before and after the introduction of the statewide CCO cigarette smoking incentive metric.ResultsAll 15 CCOs now cover cessation counseling (telephone, individual, and group) and pharmacotherapy (all 7 FDA-approved medications). The number of CCOs requiring prior authorization for at least 1 FDA-approved pharmacotherapy decreased substantially. From 2016 through 2018, the percentage of Medicaid members who reported that their health care providers recommended cessation assistance increased above baseline. The incentive metric and aligned interventions were associated with a reduction in cigarette smoking prevalence among Medicaid members, as indicated by the electronic health record metric. Thirteen of 15 CCOs demonstrated a reduction in smoking prevalence with the statewide prevalence rate decreased from 29.3% to 26.6%.Implications for Public HealthSince incentive metric implementation, progress has been made to reduce tobacco use among CCO members. Cross-agency partnerships between Medicaid and public health contributed to these successes.

Care Coordination for Vulnerable Families in the Sydney Local Health District: What Works for Whom, under What Circumstances, and Why?

Introduction:Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations.Methods:Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes.Results:Analysis indicates that care coordination has a positive impact on clients’ sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery.Conclusions:This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

Accountable care organizations and racial and ethnic disparities among patients with Alzheimer’s and related dementia diseases

AbstractBackgroundThe accountable care organization (ACO) is a new care coordination model and reimbursement mechanism that incentivizes providers to deliver high‐quality and well‐coordinated care. This study is the first to provide evidence on the ACOs enrollment and quality of enrolled ACOs among patients with ADRD, and evidence associated with racial disparities in quality of care for persons with ADRD.MethodOur study used 2017 Centers for Medicare and Medicaid Services Medicare inpatient claims data and Medicare Beneficiary Summary File. Our study focused on patients who had a diagnosis of ADRD. We further linked the CMS claims data with the 2017 MSSP ACO data to capture the patient’s participation of the ACO. The CMS ACO quality measures were used to examine the quality of the ACOs among those who enrolled in the ACOs. In this study, we examined four 4 ACO quality measures related to hospital care quality: risk standardized, all condition readmission (ACO 8), all‐cause unplanned admissions for patients with diabetes (ACO 36), heart failure (ACO 37), and multiple chronic conditions (ACO 38). Finally, we merged our data with the 2017 American Community Survey, Area Health Resource File, and the American Hospital Annual survey to capture the geographic and hospital characteristics.ResultsIn 2017, 37% of Medicare beneficiaries with ADRD were enrolled in the ACO. Substantial variation of the ACO participation by patients’ races and ethnicities was observed, ranging from 38% among the white to 14% among the Native ADRD patients. Regression results showed that compared to white, African American, Hispanic, Asian, and Native Medicare beneficiaries with ADRD were significantly less likely to enroll in the ACOs. Among those enrolled in the ACOs, we further observed ACO 8, ACO 36, ACO 37, ACO 38 were significantly higher, i.e. worse quality, among African American, Hispanic, and Native ADRD patients.ConclusionsResults suggested that policymakers should create incentives for minority‐serving providers to participate in ACOs and provide minority‐serving ACOs with structural assistance to ensure that they can successfully attain their performance goals.