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New Knowledge in Care Coordination (Text Version)

Slide presentation from the AHRQ 2008 conference showcasing Agency research and projects.

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Steven H. Woolf, M.D., M.P.H., and Alex R. Kemper, M.D., M.P.H., M.S., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (3.1 MB).

Slide 1

New Knowledge in Care Coordination

AHRQ Annual Conference
Bethesda, Maryland
September 9, 2008

Steven H. Woolf, M.D., M.P.H.
Department of Family Medicine
Virginia Commonwealth University

Alex R. Kemper, M.D., M.P.H., M.S.
Department of Pediatrics
Duke University

Slide 2


  • Agency for Healthcare Research and Quality (AHRQ).
  • Robert Wood Johnson Foundation (RWJF).

Slide 3


  • Burden of illness associated with unhealthy behaviors.
  • Potential role of clinicians and community resources.
  • Challenge of care coordination.
  • Overview of Specific Projects.
  • Lessons learned.

Slide 4

Leading Causes of Death

  • Tobacco use.
  • Diet.
  • Physical inactivity.
  • Problem drinking.

Slide 5

Chronic Care Model

The diagram shows a large, teal oval with two, blue arrows radiating downward and merging into one.

  • Community.
    • Resources and Policies.
      • Self-Management.
  • Health System.
    • Health Care Organization.
      • Delivery System Design.
      • Decision Support.
      • Clinical Information Systems.
  • These lead to Informed, Activated Patients and Prepared, Proactive Practice Teams.
    • Productive Interactions Between the Two.
  • Leads to Improved Outcomes.

Slide 6

Role of Clinicians

  • Rationale for clinician involvement.
    • Credibility and imprimatur of advice.
    • Integration with primary care and medical history.
  • Impediments.
    • Benefits of counseling depend on intensity.
    • Lack of time, skills, staff, reimbursement to offer intensive counseling and ongoing support.
    • Practice redesign to offer such services not feasible in typical US primary care practices.

Slide 7

Counseling Recommendations

  • 5As Framework for Cessation Counseling:
    • A1: Ask.
    • A2: Advise.
    • A3: Assess.
    • A4: Assist.
    • A5: Arrange.

Slide 8

The cartoon shows a doctor speaking to his patient saying, "What fits your busy schedule better, exercising one hour a day or being dead 24 hours a day."

Slide 9

Community Resources for Intensive Counseling

  • Telephone counseling (e.g., quit lines).
  • Dietitians, trainers, fitness programs.
  • Group meetings and classes (e.g., Weight Watchers).
  • Worksite and school-based wellness programs.
  • Commercial programs.
  • Public health department services.
  • Online resources and Web sites.

Slide 10

Impediments Faced by Community Programs

  • Lack of uptake.
  • Few referrals; "medical community doesn't know we are here."
  • Disconnection with primary care.
  • Fragility of community resources and public health infrastructure.
  • Medicine-public health divide.

Slide 11

The Problem of Silos

The colored photograph shows a row of silos.

Slide 12

Silo Phenomenon

The slide includes two blue rectangles. One reads, "Health Care Providers and Institutions," and the other, "Community Resources."

Slide 13

Silo Phenomenon

The two, blue rectangles show arrows going to each other.

  • Health Care Providers and Institutions.
    • Systematic identification of behaviors.
    • Brief advice.
    • Goal setting.
  • Community Resources.
    • Intensive assistance from skilled counselors.
    • Ongoing support.

Slide 14

"Win-Win" of Collaboration

  • Patients: more intensive and convenient assistance with behavior change.
  • Clinicians: relief from untenable demands.
  • Community resources: more referrals and clients.

Slide 15

Silo Phenomenon

  • The same message emanates from multiple projects sponsored by RWJF, the Centers for Disease Control and Prevention (CDC), AHRQ, academic centers, etc.
  • The themes (and solutions) are common for chronic illness care and prevention.
  • Individual projects know little about each other.
  • Policy discussion needed to address where we go from here.

Slide 16

Policy Meetings

  • Summit on Linking Clinical Practice and the Community for Health Promotion.
    • Sponsored by:
      • The American Medical Association.
      • Association of State and Territorial Health Officers.
      • Agency for Healthcare Research and Quality.
    • April 30-May 1, 2008, Baltimore, MD.
  • Prevention and Healthcare Reform Roundtable.
    • Sponsored by:
      • American Cancer Society (ACS).
      • American Heart Association.
      • American Diabetes Association.
    • July 8-9, 2008, Washington, D.C.

Slide 17

Key Questions

  • How do communities create local infrastructure, including pathways for referral and "bidirectional feedback"?
  • How can infrastructure evolve without burdening members of either silo?
  • What national/regional resources are needed to facilitate local action?
  • How can we replicate local success stories more broadly?

Slide 18

The screen shows a logo for Prescription for Health, Write It Now.

Slide 19

Prescription for Health (P4H)

  • "To identify, test, evaluate, and disseminate effective strategies for primary care clinicians and practices to help their patients be healthier by targeting 4 behaviors that are leading causes of preventable disease, disability, healthcare burden, and premature death in the U.S."
  • Funded by RWJF and AHRQ.
  • Round 1: (6/03-12/04), 17 Primary Care Practice-Based Research Networks (PBRNs) received 16-month "innovation grants" of $125,000 each.
  • Round 2: (9/05-8/07), 10 PBRNs received 24-month "innovation grants" of $300,000 each.

Slide 20

P4H Design Elements

  • ALL 10 studies.
    1. Addressed 4 health behaviors (diet, exercise, smoking AND alcohol).
    2. Were done in primary care PBRNs.
    3. Collected a common set of health behavior outcomes measures.
    4. Collected information about the practice intervention expenses.
    5. Were asked to report results using the RE-AIM framework.
    6. Systematically reported their intervention implementation experiences.

Slide 21


  • Reach.
  • Efficacy or Effectiveness.
  • Adoption.
  • Implementation.
  • Maintenance.

Slide 22

P4H Projects

  • ACORN: A Comprehensive Practice-Friendly Model for Promoting Healthy Behaviors.
  • GRIN CHERL: Connecting Primary Care Patients with Community Resources to Encourage Healthy Lifestyles.
  • NRN: Improving Health Behaviors Through Telephone Linked Care.
  • CaReNeT: Multiple Interactive Technologies to Enhance Care—MITEC (CaReNet).

Slide 23

P4H Projects

  • CECH: Healthy Teens System Project (CECH).
  • NCFPRN: North Carolina Prevention Collaborative.
  • NYC RING: Family Lifestyle Assessment of Risk.
  • OKPRN: Systematic Delivery of Brief Behavioral Counseling in Primary Care.
  • PRENSA: Engaging the Team: A Multilevel Program to Promote Healthy Behaviors.
  • RAP: Activating Primary Care and Community Resources for Health.

Slide 24

Prescription for Health Products and Resources

A screen shot of the homepage from Prescription for Health's Web site.

  • Learn more about Prescription for Health and its funded studies.
  • Access toolkit section.
  • Collaborate and communicate with funded networks.
  • Sign up for quarterly E-newsletter.

Slide 25


  • Different levels of intensity to promote care coordination between primary care practices and community resources.
    • eLinkS— use of Electronic Health Record (EHR).
    • QuitLink—use of a fax system.
    • C2P2—use of a Web site and Quality Improvement (QI) activities.

Slide 26

Virginia Ambulatory Care Outcomes Research Network (ACORN)

  • eLinkS—An Electronic Linkage System for Health Behavior Counseling (ACORN P4H Project).

Slide 27

  • The slide shows a drawn map of the State of Virginia which is dotted with ACORN locations and centered among four colored photographs of actual facilities. Right below the map is the logo for ACORN: ACORN, "Dedicated to the Longitudinal Study of Primary Care Medicine"; Virginia Ambulatory Care Outcomes Research Network.

Slide 28

Intervention Concept

  • Physicians good at A1-A3 (Ask, Advise, Agree) but lacked expertise, infrastructure, and support to adequately provide A4 (Assist) and A5 (Arrange).
  • Community resources available that already provide A4 and A5.
  • Needed an easy and systematic method to establish such a linkage.
    • Communication between counselors and clinicians was "automated" through an Electronic Medical Record (EMR).
    • Counselors contacted patients to initiate counseling (proactive counseling).

Slide 29

The chart shows the Model of Intervention.

  • Ask.*
    • Identify health behaviors: Smoking vital sign plus body mass index (BMI).
  • Advise.*
    • Brief advice: (Prompts on Healthcare Event Report [HER]).
  • Agree.*
    • Offer four options: For intensive assistance and follow-up.
  • Arrange.
    • Follow-up method.
      1. None.
      2. E-mail.
      3. Telephone.
      4. Appointment.
  • Assist.**
    1. Computer-based information library (MHL); E-counseling option (BeHIP).
    2. Telephone counseling (BeHIP).
    3. Group classes (Weight Watchers; Riverside Wellness).
    4. Usual Care.
  • Note: *Practice-based steps must be (1) brief, (2) affordable, (3) not disruptive to patient flow.
  • Note: ** Alteration of treatment preference.

Slide 30

The EMR Form

A screen shot of an opened Unhealthy P4H Behaviors form:

  • Overweight BMI.
  • Observations.
  • Patient Counseling.
  • Patient Referral Options.
  • Follow-up Options.
  • Correct Patient E-mail address.
  • Add translation to note.

Slide 31

Research Methods

  • Pre-post design.
  • 9 practices in Tidewater Virginia area
  • Prompts appear for adults with an elevated BMI, who smoke, or who drink excessively.
  • Outcomes assessed by survey, tracking systems within the EMR, counselor databases, and semi-structured interviews.

Slide 32

Health Behaviors as Recorded in the EMR (n=5679)

The slide shows both a pie chart and bar graph.

  • Pie Chart: U.B. = Unhealthy Behavior.
    • 0 U.B.: 29%.
    • 1 U.B.: 58%.
    • 2 U.B.: 12%.
    • 3 U.B.: <1 %.
  • Bar Graph.
    • None: 29%.
    • Drinker: 5%.
    • Smoker: 16%.
    • BMI 25-30: 25%.
    • BMI >30: 35%.

Slide 33

EMR Prompt System Use (5 weeks and 2 days)

The bar graph measures the EMR Prompt System Use.

  • Patients seen: 5679.
  • Unhealthy behavior: 4030.
  • Form loaded: 906.
  • Form used: 576.
  • Patients referred*: 407.
  • 10% of patients with an unhealthy behavior referred.
  • Included chronic care (42%), acute care (34%), and wellness (18%).
  • 46% would not have brought up the topic if the clinician hadn't.

Slide 34

Health Behavior Changes

The bar graphs measure patient numbers for weight loss referral and smoking referral after both two weeks and four months.

  • Referred for Weight Loss.
    • All.
      • 2 weeks: 213.
      • 4 months: 205.
    • Group.
      • 2 weeks: 207.
      • 4 months: 200.
    • Tele.
      • 2 weeks: 220.
      • 4 months: 215.
    • Usual.
      • 2 weeks: 205.
      • 4 months: 203.
  • Referred for Smoking.
    • All.
      • 2 weeks: 75.
      • 4 months: 50.
    • Group.
      • 2 weeks: 78.
      • 4 months: 55.
    • Tele.
      • 2 weeks: 67.
      • 4 months: 33.
    • Usual.
      • 2 weeks: 78.
      • 4 months: 78.

Slide 35

EMR Prompt System Use: Free vs. Patient pays

The bar graph measures the percentage of EMR Prompt System use by free of charge patients vs. the paying patient.

  • Percent loaded.
    • Free: 22%.
    • Patient Pay: 2%.
  • Percent used.
    • Free: 14%.
    • Patient Pay: 2%.
  • Percent loaded.
    • Free: 10%.
    • Patient Pay: 1%.

Slide 36

Epilogue: Virginia Department of Health (VDH) Partnership

The bar graph measures VDH partnership from June through January.

  • June: 9.
  • July: 33.
  • August: 6.
  • September: 5.
  • October: 9.
  • November: 2.
  • December: 0.
  • January: 3.
  • Note: 12 full-time-equivalents (FTEs) generated:
    • 67 referrals in 8 months.
    • 8.4 (4.9) per month.
    • Roughly 30 similar referrals/mo.

Slide 37

Virginia Ambulatory Care Outcomes Research Network (ACORN)

  • QuitLink.
    • Leveraging Community Quit Line Services to Promote Smoking Cessation Counseling.

Slide 38

QuitLink Components

  1. An expanded vital sign intervention (Ask, Advise, Assess done by staff).
  2. Capacity to provide fax referral of preparation-stage patients for proactive telephone counseling (American Cancer Society Quitline).
  3. Feedback to the provider team, including individual and aggregate reports and prescription requests.

Slide 39

Intervention Elements

  • Rooming staff used expanded vital sign.
  • Practice offered fax referral for proactive telephone counseling.
  • Patients contacted by ACS Quitline staff for intake and enrollment in 4 session counseling program.
  • Bupropion SR fax prescription request form.
  • Individual patient outcomes report.
  • Quarterly benchmarked aggregate feedback.

Slide 40

Research Methods

  • Cluster-randomized controlled trial.
    • Control—traditional tobacco-use vital sign.
  • 16 primary care practices.
    • 3 inner-city, 4 rural, and 9 suburban.
  • Included adults completing an office visit.
  • Data sources: exits survey (13,562 patients, 18% smokers), ACS minimal data set, and semi-structured interviews.

Slide 41

Principal Findings

The table is divided into six columns: Counseling Behavior, Survey Question, and Adjusted Affirmative Response for Control, Intervention, Difference, and P Value. The first row reads: Ask (A1), "Did anyone ask you today if you smoke?"; Control-64.5%; Intervention-59.6%; Difference-4.9%; and p Value-0.45. The second row reads: Advise (A2), "If you smoke, did anyone advise you today to stop smoking?"; Control-55.1%; Intervention-57.9%; Difference-2.8%, and p Value-0.40.

Slide 42

Principal Findings

The table continues from the previous slide. The first row reads: Intensive Counseling (A3-5 plus Referral); Main Outcome; Control-29.5%; Intervention-41.4%; Difference-11.9%; p Value-<0.001. The second row reads: Discussion (A3-5); "If you smoke, did anyone talk with you today about ideas or plans to help you quit smoking?"; Control-28.7%; Intervention-35.2%; Difference-6.5%; and p Value-0.001. The third row reads: Referral; "If you smoke, were you referred today to a quit line?"; Control-8.7%; Intervention-21.4%; Difference-12.7%; and p Value-<0.001.

Slide 43

Clinician and Community Partnership for Prevention

  • Goal: To evaluate strategies to develop and foster sustainable linkages between primary care practices and existing community resources to help patients address.
    • Tobacco use.
    • Poor nutrition.
    • Physical inactivity.

Slide 44


A screen shot of the homepage for ACCTION Pack's Web site.

Slide 45


An antiquated map of North Carolina.

  • Orange County:
    • Population: 120,000.
    • Black: 13%.
    • Hispanic: 6%.
  • Durham County:
    • Population 230,000.
    • Black 37%.
    • Hispanic 11%.
    • Overall, 13% below Federal Poverty Level (FPL).
  • In North Carolina.
    • Tobacco: 25%.
    • ≥20 minutes physical activity ?3 days per week: <25%.
    • Overweight: 36%.
    • Obese: 27%.
    • Ready to change: 44% who smoke, 60% with poor nutrition, 68% who lack exercise.

Slide 46

Participants and Interventions

The diagram shows 9 Practices (IM and FP) lead to R which leads to either Control, Passive Intervention, or Active Intervention with the duration of the intervention being 6 months.

Slide 47

Control Practices

  • Before and after survey to determine:
    • Current Referral Strategies.
    • Practice Organization.
  • Chart audits at the beginning, middle and end of the intervention to evaluate:
    • Patient population that could benefit from referral to a community organization.
    • Actual Referral patterns.

Slide 48

Passive Intervention

  • Protocol per control practices plus:
    • Brochure and referral material for selected community organizations:
      • NC Tobacco Quitline.
      • YMCA.
      • Public Health Department Dieticians.
      • Duke "Live for Life" Program.
    • Practice kick-off meeting.
    • Brief help as requested.

Slide 49

Practice Brochure

The slide shows partial document images from three brochures: North Carolina Network Consortium: Community and Clinician Partnership for Prevention, Healthy Choices for a Healthy Lifestyle, and Resources to Support Healthy Choices.

Slide 50

Practice Brochure

A document image from a brochure showing information on quitting tobacco use, good diet, and exercise, as well as supplying a coupon for a guest pass to the YMCA.

Slide 51

Active Intervention

  • Passive Intervention Protocol plus:
    • Practice Champion who will.
      • Identify other community resources.
      • Receive feedback, including number of referrals made and completed, outcomes of chart audits.
      • Follow-up a small number of referrals.
      • Monthly QI phone call with other active practices and community resource representatives.
    • Access to the "ACCTION Pack."

Slide 52


A screen shot of the "Tool Selector" page from ACCTION Pack's Web site.

Slide 53

Outcome Measures

  • Main.
    • Referral to a community resource.
  • Secondary.
    • Completion of referral.
    • Changes in provider knowledge and attitudes towards partnerships.
    • Description of the barriers to and facilitators of developing linkages between practices and community resources.
    • Use of the ACCTION Pack.

Slide 54


  • What are the minimal features of a community resource?
  • How to assess with the practices about whether something is really a community resource (e.g., a mall walking program)?
  • How can community resources be identified and tracked efficiently?
  • How to develop reproducible strategies for bidirectional communication between practices and community resources?
  • How to get others to add to the ACCTION Pack?

Slide 55

Lessons Learned

  • Research challenges.
    • Process measures vs. Health Outcomes.
    • Generalizability.
    • Primary Prevention vs. Secondary Prevention.
    • Evidence Base for Choosing Interventions.

Slide 56

Lessons Learned

  • Integration of behavior change counseling is feasible in frontline primary care practice.
  • Obstacles to practices include inadequate.
    • Resources.
    • Tools.
    • Reimbursement.
    • Awareness.
  • Substantial practice redesign and revised reimbursement systems are necessary.
  • Multifaceted solutions involving new tools, technologies, and care teams are now available.

Slide 57

Lessons Learned

  • The parallels of addressing chronic care illness and preventive health care can be leveraged to significantly improve both.
  • Models and frameworks such as the 5As, the Chronic Care Model, and RE-AIM are valuable guides in the implementation of innovations into practice.
  • Integration of behavior change strategies extends beyond the exam room, beyond a single visit, and beyond the office.
  • Integration of clinical and community services to achieve behavior change is both challenging and critical. The infrastructure to make the connection is broken, fragile, or lacking.
Current as of February 2009
Internet Citation: New Knowledge in Care Coordination (Text Version). February 2009. Agency for Healthcare Research and Quality, Rockville, MD.


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