Clinical Care Coordination Research Articles

The pharmacist’s personal IMPACT

At all of the diverse Project IMPACT: Diabetes sites, pharmacists are having firsthand experience with the effectiveness of personal contact with patients. By encouraging patients to adhere to their medications, helping them navigate the tricky waters of the health care system, or simply listening to their concerns, pharmacists can make a difference just by their presence.

Lessons Learned for Collaborative Clinical Content Development

Site-specific content configuration of vendor-based Electronic Health Records (EHRs) is a vital step in the development of standardized and interoperable content that can be used for clinical decision-support, reporting, care coordination, and information exchange. The multi-site, multi-stakeholder Acute Care Documentation (ACD) project at Partners Healthcare Systems (PHS) aimed to develop highly structured clinical content with adequate breadth and depth to meet the needs of all types of acute care clinicians at two academic medical centers. The Knowledge Management (KM) team at PHS led the informatics and knowledge management effort for the project. We aimed to evaluate the role, governance, and project management processes and resources for the KM team's effort as part of the standardized clinical content creation. We employed the Center for Disease Control's six step Program Evaluation Framework to guide our evaluation steps. We administered a forty-four question, open-ended, semi-structured voluntary survey to gather focused, credible evidence from members of the KM team. Qualitative open-coding was performed to identify themes for lessons learned and concluding recommendations. Six surveys were completed. Qualitative data analysis informed five lessons learned and thirty specific recommendations associated with the lessons learned. The five lessons learned are: 1) Assess and meet knowledge needs and set expectations at the start of the project; 2) Define an accountable decision-making process; 3) Increase team meeting moderation skills; 4) Ensure adequate resources and competency training with online asynchronous collaboration tools; 5) Develop focused, goal-oriented teams and supportive, consultative service based teams. Knowledge management requirements for the development of standardized clinical content within a vendor-based EHR among multi-stakeholder teams and sites include: 1) assessing and meeting informatics knowledge needs, 2) setting expectations and standardizing the process for decision-making, and 3) ensuring the availability of adequate resources and competency training.

Living Smart, Living Fit

Depression and obesity/overweight during pregnancy are important public health concerns, as they are frequently associated with poor birth outcomes. The Living Smart, Living Fit® (LSLF) program was an intervention program initiated in 2008 to provide comprehensive care to low-income pregnant and postpartum women with elevated body mass index (BMI) and depressive symptoms. It linked patients to clinical care coordinators trained in motivational interviewing who promoted participation in a portfolio of mental and physical wellness activities. The objective of this study was to evaluate the effectiveness of LSLF in improving depression, BMI, birth weight, and smoking status among low-income perinatal patients. Women with Patient Health Questionnaire (PHQ-9) depression scores ≥10 and/or BMI >25 kg/m(2) at their prenatal intake visit were eligible for enrollment into the LSLF program. Enrolled participants met with clinical care coordinators who encouraged engagement in a portfolio of LSLF activities that included pregnancy/family, physical health, and mental health interventions. Outcomes were measured at the 6-week postpartum visit and included change in PHQ-9 scores, change in BMI, birth weight, and change in smoking status. Of the 107 enrollees, 86% participated in some LSLF activity. Participation in pregnancy/family related activities was significantly associated with decreased PHQ-9 scores. Participation in mental health services was significantly associated with increased birth weight. No changes in BMI or smoking status were associated with LSLF involvement. The findings of this pilot study indicate that pregnant women with depression or obesity/overweight can benefit from care coordination and a portfolio of activities for mental and physical wellness. The LSLF program provides a model for delivering this patient-centered comprehensive support. Further research should include more controlled trials to better evaluate the effectiveness of LSLF intervention.

A Physician Hospital Organization's Approach to Clinical Integration and Accountable Care

A Physician Hospital Organization's Approach to Clinical Integration and Accountable Care

Older Physicians Leery of Info Technology

Physicians in eight countries agree that health information technology has the potential to improve clinical data and care coordination while reducing medical errors, according to a new survey. However, physicians in the United States and doctors older than 50 voiced considerably more skepticism than did their younger and international colleagues about the ability of HIT to improve care. The survey, conducted by global consulting firm Accenture, found that physicians who haven't used the technology are most skeptical, but once they start to use HIT, they begin to see those benefits, said Frances Dare, a senior executive with Accenture Health. Accenture surveyed 500 doctors per country in Australia, Canada, England, France, Germany, Spain, and the United States, along with 200 doctors in Singapore, in August and September 2011. The researchers found that nearly 71% of physicians think that HIT will improve data for clinical research, and 69% think it will improve coordination of care. About two-thirds think it will lead to a reduction in medical errors, and about 65% think it will lead to better health care decisions. However, fewer than 50% of physicians think it will lead to less litigation, and a similar minority thinks it will lead to fewer unnecessary procedures or increased speed of access to health services for patients. Ms. Dare said that policy makers and companies involved in the HIT field have tended to focus on how the technology can reduce costs and unnecessary care, whereas this survey shows that physicians care more about how HIT can improve access to care and care coordination for patients. More than 72% of physicians younger than age 50 said that electronic medical records and health information exchanges will improve care coordination, and 73% predicted better data for clinical research. Among older physicians, only 65% said research data will improve, and 68% predicted better care coordination will improve. Opinions were more negative among physicians in the United States, according to Accenture. Only 45% of U.S. physicians said HIT will improve diagnostic decisions, compared with 61% of all physicians surveyed. And 45% of U.S. physicians believe that HIT leads to improved outcomes, compared with 59% of all physicians. The United States “is behind,” Ms. Dare said. Still, she said she believes the United States can catch up quickly if more physicians begin to use HIT and see the benefits from it.

Where Are My Patients? It Is Time to Automate Notification of Hospital Use to Primary Care Practices

The hospital-to-community transition is fraught with risks for patients, with 30-day readmission rates of 20% for Medicare patients. Poorly coordinated transitions of care translate to unplanned readmission costs to Medicare of more than $17 billion/year. Calls for better physician communication to improve care coordination abound; however, primary care physicians cannot better coordinate care when, in many cases, they are not even aware that their patients have been admitted to the hospital. During the past 30 years, we have made little progress in systematically improving communication between hospital and posthospital providers to coordinate postdischarge care. Hospitals and physicians need better tools to coordinate care transitions. It is time to automate the hospital discharge notification process, notify practice staff, and stop expecting physician-to-physician communication. Notification can be efficiently supported by computerized systems that do not rely on physicians to "close the loop" back to primary care. We present four clinical programs in which automated notification of primary care staff was used to ensure appropriate follow-up and coordination of care for patients. These automated systems use a secure online Web site or an encrypted e-mail notification system that alerts clinicians and practice staff to hospital registration of the patient. In each program, notification triggers a nurse-directed clinical assessment and care coordination plan and helps ensure timely primary care follow-up. We believe automated notification is a necessary tool to support coordination of care in the new delivery models such as the patient-centered medical home.

Studying Clinical Communication to Inform Health Information Technology Design

Information technology has the potential to significantly improve communication and coordination in health care. However, current technologies frequently impede clinical communication. A major reason for this discrepancy is due to lack of consideration of how clinical communication and coordination of care occur, which requires studying “in the wild”, such as using a human factors engineering approach. In this panel, the speakers will share their experiences regarding (1) how to study clinical communication and (2) what we can learn from studying clinical communication studies to inform future information technology design for health care. The panel members will address these questions based on their research studies and literature.

Nurses' needs in delivering palliative care for long-term conditions

This study addressed the question 'What are the needs of community nurses in delivering palliative care to people with long-term conditions?' A qualitative exploratory descriptive design was employed. Ten community nurses (Band 5-7) were recruited from a purposive sample following a process of randomised stratified sampling, according to geographical area and Band for matched numbers. Semi-structured interviews were undertaken and audio recorded with written informed consent. The interviews were transcribed verbatim and analysed using an adapted Burnard's framework. The study found that establishing therapeutic relationships, having access to resources, co-ordination and provision of clinical care and collaborative working were all highlighted by the community nurses as needs in delivering palliative care. If these four needs were met, the community nurses believed they could deliver palliative care to their patients. Issues around a lack of resources, community nurses' educational needs and the late referral of patients with non-malignant long-term conditions to community nursing were also identified.

Validating the Clinical Research Nursing Domain of Practice

To develop and validate a taxonomy for the domain of clinical research nursing. Survey. Clinical research settings in the United States. A purposefully selected expert panel of 22 nurses who were actively practicing or supervising in a clinical research environment. A study team consisting of nurses with experience in clinical research synthesized peer-reviewed articles, academic curricula, professional guidelines, position descriptions, and expert opinion. Using the Delphi technique, three rounds of surveys were conducted to validate the taxonomy. The three sequential questionnaires were completed over five months. Activities performed by nurses in a clinical research setting. A taxonomy for clinical research nursing was validated with five dimensions and 52 activities: Clinical Practice (4 activities), Study Management (23 activities), Care Coordination and Continuity (10 activities), Human Subjects Protection (6 activities), and Contributing to the Science (9 activities). This study validated activities for direct care providers and nurses with the primary focus of research coordination. The findings identify a variety of activities that are unique to nurses in a clinical research setting. Nurses play an integral role in the clinical research enterprise. Validating a taxonomy for the specialty of clinical research nursing allows for roles to be compared across settings, competency requirements to be defined, and nursing organizations to be guided in the development of specialty certification.

Electronic Health Records and the Implications for Nursing Practice

Electronic health record (EHR) systems can improve communication and coordination of clinical care, resulting in better health-care outcomes. Current regulations focus on documentation requirements that support clinical care, billing compliance, and the privacy and security of EHRs. The ultimate goal is to ensure that each EHR system has the capacity to electronically communicate through a national health information network, while providing each citizen access to his or her EHR.

Patient‐centered Integrated Networks of Emergency Care: Consensus‐based Recommendations and Future Research Priorities

Patient-centered care is defined by the Institute of Medicine (IOM) as care that is responsive to individual patient needs and values and that guides the treatment decisions. This article is a result of a breakout session of the 2010 Academic Emergency Medicine (AEM) consensus conference and describes the process of developing consensus-based recommendations for providing patient-centered emergency care. The objectives of the working group were to identify and describe the critical gaps in the provision of patient-centered care, develop a consensus-based research agenda, and create a list of future research priorities. Using e-mail and in-person meetings, knowledge gaps were identified in the areas of respect for patient preferences, coordination of clinical care, and communication among health care providers. Four consensus-based recommendations were developed on the following themes: enhancing communication and patient advocacy in emergency departments (EDs), facilitating care coordination after discharge, defining metrics for patient-centered care, and placing the locus of control of medical information into patients' hands. The set of research priorities based on these recommendations was created to promote research and advance knowledge in this dimension of clinical care.

Newborn dried bloodspot screening: Long-term follow-up activities and information system requirements

PurposeTo describe the clinical and public health activities of all entities involved in long-term follow-up of children with conditions identified by newborn dried bloodspot screening, including the requirements for interoperable clinical and public health information systems that will support care from birth through adulthood. MethodsThe Southeastern Newborn Screening Genetics Collaborative (Region 3) convened a workgroup of experts in pediatric care, genetics, and public health, facilitated by the Public Health Informatics Institute (the Institute). The Institute's Collaborative Requirements Development Methodology was used. ResultsThree overlapping steps in the long-term follow-up process were examined: needs assessment, ongoing treatment/management, and knowledge generation. In addition, greater definition was given to the roles of Clinical Care Coordinator and Public Health Care Coordinator, as defined by a previous workgroup, and a new role was identified—Care Plan Leader (primary care provider or specialist) who would serve as treatment coordinator and centralize long-term follow-up care provision to minimize gaps in clinical care. ConclusionThe outcome of the Region 3 Workgroup's efforts is an expanded notion of long-term follow-up to extend throughout the patient's lifespan, with an emphasis on the coordination of care involving both clinical and public health sectors and on requirements for interoperable clinical and public health information systems.

An integrated health and social care organisation in Sweden: Creation and structure of a unique local public health and social care system

Research and citizens have noted failures in coordinating health and social services and professionals, and the need to address this issue to realize benefits from increasing specialisation. Different methods have been proposed and one has been structural integration of separate services within one organisation. This paper reports an empirical longitudinal study of the development of an integrated health and social care organisation in Sweden combining service provision, purchasing and political governance for a defined population. The study found a combination of influences contributed to the development of this new organisation. The initial structural macro-integration facilitated, but did not of itself result in better clinical care coordination. Other actions were needed to modify the specialised systems and cultures which the organisation inherited. The study design was not able to establish with any degree of certainty whether better patient and cost outcomes resulted, but it did find structural and process changes which make improved outcomes likely. The study concludes that coordinated actions at different levels and of different types were needed to achieve care coordination for patients and that a phased approach was necessary where management capacity and outside expertise are limited.

Care Coordination in Intensive Care Units: Communicating Across Information Spaces

This study explores the interactions among phases of team coordination, patient-related information, decision-making levels, and role holders in intensive care units (ICUs). The effects of communication improvement initiatives on adverse patient events or improved outcomes have been difficult to establish. Conceptual inconsistencies and methodological shortcomings suggest insufficient understanding about clinical communication and care coordination. Data were collected by shadowing a charge nurse, fellow, resident, and nurse in each of eight ICUs and recording each of their conversations during 12 hrs (32 role holders during 350 hrs). Hierarchical log linear analyses show statistically significant three-way interactions between the patient information, phases of team coordination, and decision levels, chi2(df = 75) = 212, p < .0001; between roles, phases of team coordination, and decision levels, chi2(df = 60) = 109, p < .0001; and between roles, patient information, and decision levels, chi2(df = 60) = 155, p < .0001. Differences among levels of the variables were evaluated with the use of standardized parameter estimates and 95% confidence intervals. ICU communication and care coordination involve complex decision structures and role interactions across two information spaces. Different role holders mediate vertical and lateral process flows with goals and directions representing an important conceptual transition. However, lateral isolation within decision levels (charge nurses) and information overload (residents) are potential communication and care coordination vulnerabilities. Results are consistent with and extend the findings of previous studies. The profile of ICU communication and care coordination provides a systemic framework that may inform future interventions and research.

Transforming Singapore's healthcare delivery system: health care integration in Singapore

Purpose: The vision for transforming healthcare delivery in Singapore is to develop integrated Regional Health Services (RHS) to provide healthcare from prevention to palliation. Under the RHS concept, each region would be anchored by an acute-care hospital working in close partnership with other healthcare providers in the region, e.g. general physicians (GPs), polyclinics, community hospitals (CHs), nursing homes (NHs) and home care providers. Formalized partnerships, integrated clinical pathways and care coordinators working with a multi-disciplinary team over the patient’s lifetime would help keep the care continuous, seamless and appropriate. Achieving this vision will require us to (i) significantly build up the ILTC and primary care sectors; and (ii) restructure our public healthcare system and strengthen the enablers and linkages between providers in each region to better integrate care and enable the entire system to work as it should. Agency for integrated care: A key part of achieving this vision is the development of a national care integrator: the Agency for Integrated Care (AIC). Formed in 2008, the AIC coordinates referrals to intermediate and long-term care services as well as facilitates discharge planning for patients discharged from acute-care hospitals through hospital-based ACTION Teams. To support the development of integrated RHS, its role will be expanded progressively to include a focus on developing the capabilities of local healthcare service providers as well as patient education. (Please see separate item presented by AIC that will focus on the work of the ACTION Teams—to show that ACTION teams through care coordination helps to reduce Average Length of Stay (ALOS) in acute settings, foster interagency collaboration and improve access to services for patients.) Context: In Singapore as in other countries, we face the twin challenges of an aging population and the growing burden burden of chronic disease. The current model of acute-care centered provision of healthcare has to transform and new services and linkages need to be developed to cater for the health needs of the elderly population and improve overall population health. Data Sources: MOH/healthcare providers. Case description: Development of integrated Regional Health Services. Discussion: Implementation of an integrated RHS model and challenges.

Addressing service deficits for the physically disabled in New Zealand: An action research study

As a consequence of the global trend towards new managerialism the New Zealand government undertook reforms of the health-care system during the 1980s and 1990s. These reforms, to a system that had functioned essentially unchanged since the 1930s, improved fiscal accountability at the expense of ensuring continuity of care. The restructuring particularly affected vulnerable populations with permanent disability and long-term health needs. This study sought to address the service deficits of the current health service delivery system and to identify strategies to ensure continuity of care for this group. The development of a clinical pathway and the appointment of a clinical care coordinator to oversee the delivery of comprehensive seamless health-care services were the major recommendations resulting from this study.

Interprofessional Education: Principles and Application A Framework for Clinical Pharmacy

With the increasing prevalence of chronic diseases, advancements in health care technology, and growing complexity of health care delivery, the need for coordination and integration of clinical care through a multidisciplinary approach has become essential. To address this issue, the Institute of Medicine has called for a redesign of the health professional education process to provide health care professionals, both in the academic setting and in practice, the knowledge, skills, and attitudes to work effectively in a multidisciplinary environment. Such programmatic redesign warrants the implementation of interprofessional education (IPE) across health care disciplines. Pharmacists play a critical role not only in the provision of patient care on multidisciplinary teams but also in the delivery of IPE. National pharmacy organizations have endorsed IPE, and several have articulated specific policies and/or initiatives supporting IPE. However, IPE has not yet been implemented effectively or consistently; moreover, the inability to effectively deliver IPE in the classroom and clinic has been correlated with a decrease in the quality of patient care provided. In addition, the incorporation of interprofessional patient care into daily practice has been compromised by workforce shortages within respective health care fields. This White Paper from the American College of Clinical Pharmacy (ACCP) addresses terminology, levels of evidence, environment‐specific models, assessment methods, funding sources, and other important implications and barriers as they apply to IPE and clinical pharmacy. Current instruments that have been tested and validated in the assessment of IPE are reviewed, including the Readiness for Interprofessional Learning Scale, the Interdisciplinary Education Perception Scale, and the Attitudes Toward Health Care Teams Scale. Finally, strategies are suggested that ACCP might pursue to assist in the promotion and implementation of IPE both within and outside the pharmacy profession.

Monitoring and Improving Resident Work Environment Across Affiliated Hospitals: A Call for a National Resident Survey

To assess, monitor, and improve resident work environment and enhance compliance with Accreditation Council for Graduate Medical Education (ACGME) institutional requirements among the five Loma Linda University-affiliated hospitals using an annual survey. From 2001 to 2005, residents completed an anonymous questionnaire assessing each hospital's educational and work environment regarding clinical services, attending physicians, learning opportunities, resident environment, and coordination of care. Resident perceptions were compared across hospitals and residency programs. A total of 2,399 resident surveys were collected during a five-year period from 500 residents in 43 different residency programs. The overall response rate was 88%. Residents perceived deficiencies in clinical services at the Veterans Affairs (VA) hospital. After focused improvement efforts directed to VA clinical services, serial data showed significant improvements in residents' perceptions of nursing, phlebotomy, radiology, social work, case management, and overall clinical services in subsequent years (P < .001). The survey data identified resident concerns at other affiliated hospitals and were instrumental in persuading hospital administrators to improve the university hospital resident lounge and computerized lab results at a county hospital. Resident perceptions improved in subsequent years after the changes were made (P < .001). The survey also suggested improvements in residency-specific program educational issues. A survey across five consecutive years involving five affiliated hospitals provided local benchmarks and serial data to monitor and significantly improve resident perceptions of their work environment and ensured optimal compliance with ACGME institutional requirements. These results and the data of others support the idea of an expanded, national resident survey.

Acute clinical care and care coordination for traumatic brain injury within Department of Defense

The nature of current combat situations that U.S. military forces encounter and the use of unconventional weaponry have dramatically increased service personnel's risks of sustaining a traumatic brain injury (TBI). Although the true incidence and prevalence of combat-related TBI are unknown, service personnel returning from deployment have reported rates of concussion between 10% and 20%. The Department of Defense has recently released statistics on TBI dating back to before the wars in Iraq and Afghanistan to better elucidate the impact and burden of TBI on America's warriors and veterans. Patients with severe TBI move through a well-established trauma system of care, beginning with triage of initial injury by first-responders in the war zone to acute care to rehabilitation and then returning home and to the community. Mild and moderate TBIs may pose different clinical challenges, especially when initially undetected or if treatment is delayed because more serious injuries are present. To ensure identification and prompt treatment of mild and moderate TBI, the U.S. Congress has mandated that military and Department of Veterans Affairs hospitals screen all service personnel returning from combat. Military health professionals must evaluate them for concussion and then treat the physical, emotional, and cognitive problems that may surface. A new approach to health management and care coordination is needed that will allow medical transitions between networks of care to become more centralized and allow for optimal recovery at all severity levels. This article summarizes the care systems available for the acute management of TBI from point of injury to stateside military treatment facilities. We describe TBI assessment, treatment, and overall coordination of care, including innovative clinical initiatives now used.

Veterans Health Administration and Indian Health Service

The Veterans Health Administration (VHA) and Indian Health Service (IHS) have executed an agreement to share resources to improve access and health outcomes for American Indian and Alaska Native (AIAN) veterans. To describe the extent of dual use, health needs, and utilization patterns for IHS-enrollees served by VHA and IHS. Our objective is to fill those gaps in knowledge to inform strategic planning between these federal agencies. Secondary data analysis of linked and merged VHA and IHS centralized administrative data from FY02 and FY03. Of 64,746 IHS enrollees who used VHA and/or IHS, 25% accessed care at both healthcare organizations, whereas most used either the VHA (28%) or the IHS (46%). The proportion of dual users varied markedly by state. Like all other VHA users, these AIAN veterans have the same 3 most frequent diagnoses associated with healthcare encounters: posttraumatic stress disorder, hypertension, and diabetes. VHA-IHS dual users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VHA. Many dual users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping attention in VHA and IHS. Strategies to improve outcomes for AIAN veterans should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Strategies to improve access may differ regionally.