National Healthcare Quality Report, 2013
Chapter 7. Care Coordination
Health care in the United States is often fragmented. Clinical services are frequently organized around small groups of providers who function autonomously and specialize in specific symptoms or organ systems. Therefore, many patients receive attention only for individual health conditions rather than receiving coordinated care for their overall health. For example, the typical Medicare beneficiary sees two primary care providers and five specialists each year (Bodenheimer, 2008). Communication of important information among providers and between providers and patients may entail delays or inaccuracies or fail to occur at all.
Care coordination is a conscious effort to ensure that all key information needed to make care decisions is available to patients and providers. It is defined as the deliberate organization of patient care activities between two or more participants involved in a patient's care to facilitate appropriate delivery of health care services (Shojania, et al., 2007). Care coordination is multidimensional and essential to preventing adverse events, ensuring efficiency, and making care patient centered (Powell-Davies, et al., 2008).
Patients in greatest need of care coordination include those with multiple chronic medical conditions, concurrent care from several health professionals, many medications, extensive diagnostic workups, or transitions from one care setting to another. Effective care coordination requires well-defined multidisciplinary teamwork based on the principle that all who interact with a patient must work together to ensure the delivery of safe, high-quality care.
In early 2011, the Partnership for Patients was created to improve the quality, safety, and affordability of health care for all Americans. One of the two major goals of this public-private partnership is to heal patients without complications arising. This goal specifically ties to care coordination by seeking to decrease preventable complications during transitions from one care setting to another. The objective was to decrease all hospital readmissions by 20% overall by the end of 2013 (compared with 2010).
One example of the Federal Government's efforts to support care coordination is the Health Resources and Services Administration's initiative "Enhancement & Evaluation of Existing Health Information Electronic Network Systems for PLWHA (People Living With HIV/AIDS) in Underserved Communities." Begun in 2007, the initiative funded six demonstration sites throughout the Nation for up to 4 years.i
Another more recent funding opportunity also offered by HRSA is "Systems Linkages and Care Initiative to High Risk Populations Evaluation and Technical Assistance Center." This initiative promotes the development of innovative strategies to successfully integrate different components of the public health system into quality HIV care for hard-to-reach populations who have never been in care.
The Agency for Healthcare Research and Quality (AHRQ) intends this chapter to be the leading step in the evolving national discussion on measuring care coordination. Furthermore, AHRQ hopes that this chapter will stimulate productive discussions in the area of care coordination, including development and use of valid, reliable, and feasible quality measures.
Morbidity and Mortality
Care coordination interventions have been shown to:
- Reduce mortality among patients with heart failure.
- Reduce mortality and dependency among patients with stroke.
- Reduce symptoms among patients with depression and at the end of life.
- Improve glycemic control among patients with diabetes (Shojania, et al., 2007).
Care coordination interventions have been shown to:
- Reduce hospitalizations among patients with heart failure.
- Reduce readmissions among patients with mental health conditions.
- Be cost-effective when applied to treatment of depression (Shojania, et al., 2007).
The National Strategy for Quality Improvement in Health Careii identified care coordination as one of six national priorities for health care. The vision is health care providers, patients, and caregivers all working together to "ensure that the patient gets the care and support he needs and wants, when and how he needs and wants it." While measurement of care coordination is at an early stage in development, key goals include coordinating transitions of care, reducing hospital readmissions, communicating medication information, and reducing preventable emergency department visits.
Measures reported in this chapter are organized around these goals:
- Transitions of care:
- Adequate hospital discharge information.
- Integration of information:
- Provider asking about medications and treatments from other doctors.
- Electronic exchange of medication information.
- Information gathering by home health care providers.
- Care for children with special health care needs (CSHCN):
- CSHCN with effective care coordination.
- CSHCN with a medical home.
Transitions of Care
As health care conditions and needs change, patients often need to move from one setting to another. These transitions of care place patients at heightened risk of adverse events. Important information may be lost or miscommunicated as responsibility is delivered to new parties.
Management: Complete Written Discharge Instructions
Effective care coordination begins with ensuring that accurate clinical information is available to support medical decisions by patients and providers. A common transition of care is discharge from the hospital. Giving patients and caregivers self-management support after discharge has been shown to reduce readmissions to the hospital and lower costs (Coleman, et al., 2006).
Discharge from a hospital typically indicates improvement in a patient's condition so that the patient no longer requires inpatient care. It also means that the patient and family must resume responsibility for the patient's daily activities, diet, medications, and other treatments. The patient also needs to visit his or her personal doctor and know what to do if his or her condition deteriorates. Written discharge instructions are critical to help ensure that a patient receives the information needed to stay healthy after leaving the hospital.
Figure 7.1. Hospitalized adult patients with heart failure who were given complete written discharge instructions, by age and sex, 2005-2011
Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program, 2005-2011.
Denominator: Hospitalized adult patients with a principal discharge diagnosis of heart failure.
Note: Complete written discharge instructions needed to address all of the following: activity level, diet, discharge medications, followup appointment, weight monitoring, and actions to take if symptoms worsen.
2010 Achievable Benchmark: 94%.
- From 2005 to 2011, the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved from 57.4% to 92.0% (data not shown).
- Improvements were observed among all age groups and both sexes (Figure 7.1).
- There were no statistically significant differences by age or sex.
- The 2010 top 5 State achievable benchmark was 94%.iii At the current 6% annual rate of increase, this benchmark could be attained overall and by all age groups and both sexes in less than a year.
Also, in the National Healthcare Disparities Report (NHDR):
- Improvements were observed among all racial and ethnic groups.
Integration of Information
Patients often seek care from many providers. Medical information generated in different settings may not be sent to a patient's primary care provider. Actively gathering and managing all of a patient's medical information is an important part of care coordination. Tasks include ensuring that patients are informed of important findings such as test results, primary care doctors are informed of care from specialists, and providers within a practice have access to needed information.
Management: Provider Asking About Medications From Other Doctors
Different providers may prescribe medications for the same patient. Patients are responsible for keeping track of all their medications, but medication information can be confusing, especially for patients on multiple medications. When care is not well coordinated and some providers do not know about all of a patient's medications, patients are at greater risk for adverse events related to drug interactions, overdosing, or underdosing.
In addition, providers need to periodically review all of a patient's medications to ensure that they are taking what is needed and only what is needed. Medication reconciliation has been shown to reduce both medication errors and adverse drug events (Whittington & Cohen, 2004).
Medication information generated in different settings might not be sent to a patient's primary care provider. In the absence of communication from other providers, the patient is the primary source of medication information. Actively gathering and managing all of a patient's medical information is an important part of care coordination.
Figure 7.2. People under age 65 with a usual source of care whose health provider usually asks about prescription medications and treatments from other doctors, by insurance and activity limitations, 2002-2010
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population who report a usual source of care.
Note: Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.
- From 2002 to 2010, the percentage of people with a usual source of care whose health provider usually asked about prescription medications and treatments from other doctors improved from 75.1% to 82.8% (Figure 7.2).
- In the last 3 years (2008-2010), people with public insurance were less likely than people with private insurance to be asked about prescription medications and treatments from other doctors.
- In 2010, more than 80% of people with a usual source of care were asked about prescription medications and treatments from other doctors, regardless of activity limitation.
Also, in the NHDR:
- From 2008 to 2010, there were no statistically significant differences by perceived health status.
Structure: Electronic Exchange of Medication Information
Ideally, information about medications prescribed for a patient by one provider would be available to all providers taking care of that patient. One way to exchange this information efficiently is to build this function into health information technologies. The American Hospital Association recently surveyed hospitals about their use of health information technologies. Questions about whether a hospital electronically exchanged patient information on medication history with other providers were included, and 2,112 hospitals responded.
Figure 7.3. Hospitals with electronic exchange of patient information on medication history, by ownership and bed size, 2009-2011, electronic exchange with hospitals outside their system and with ambulatory providers outside their system
Source: American Hospital Association Annual Survey Information Technology Supplement, 2009-2011.
- In 2011, 25.2% of hospitals electronically exchanged patient information on medication history with hospitals outside their system, up from 19.4% in 2010. Although 31.8% of hospitals exchanged information with ambulatory providers outside their system, this was down from 32.1% in 2010 (Figure 7.3).
- Federal hospitals were most likely to have electronic exchange with hospitals outside their system, followed by nonprofit, non-Federal, and for profit (investor owned) (33.3%, 28.3%, 21.8%, and 16%, respectively).
- Hospitals with <100 or 100-399 beds were less likely than large hospitals (400+ beds) to exchange information with hospitals outside their system. Large hospitals also were more likely than medium and small hospitals (46.2%, 35.8%, and 24.9%, respectively) to have electronic exchange with ambulatory providers outside their system.
- In 2011, nonprofit hospitals were most likely to have electronic exchange with ambulatory providers outside their system, followed by non-Federal, Federal, and for profit.
Also, in the NHDR:
- In 2011, hospitals in the West were the most likely to exchange information with ambulatory providers outside their system, followed by hospitals in the Northeast, Midwest, and South.
New! Management: Information Gathering by Home Health Care Providers
Home health care providers deliver a variety of services to patients in their homes, including medication and pain management, wound care, and patient education. Coordination with referring physicians is critical to ensure that patients receive the services and medications they need.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Care Survey (Home Health Care CAHPS Survey) was designed to measure the experiences of people receiving home health care from Medicare-certified home health care agencies. In April 2012, the Centers for Medicare & Medicaid Services began publicly reporting results from this survey on Home Health Compare to create incentives for home health agencies to improve quality of care and to provide patients with information to help them choose home health care providers. The results presented here reflect data collected from a sample of patients who received home health care between October 2011 and September 2012.
Figure 7.4. Information gathering by home health care providers among adults receiving home health care, by language spoken at home, 2011-2012
Source: Centers for Medicare & Medicaid Services, Home Health Care CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey, 2011-2012.
Denominator: Adults who had at least two visits from a Medicare-certified home health agency during a 2-month look-back period. Patients receiving hospice care and who had "maternity" as the primary reason for receiving home health care are excluded.
- In 2011-2012, among adult home health care patients, 83.8% reported that home health care providers talked with them about all the medicines they took, 78.8% asked to see all the medicines they took, and 62.2% always seemed informed about all the care they got at home (Figure 7.4).
- Adult home health care patients who spoke Spanish or a language other than English at home were more likely than English speakers to report that home health care providers talked with them about their medicines and asked to see all the medicines they took.
- Adult home health care patients who spoke a language other than English at home were less likely than English speakers to report that home health care providers always seemed informed about all the care they got at home.
Also, in the NHDR:
- Black and Hispanic adult home health care patients were more likely than White patients to report that home health care providers talked with them about all the medicines they took.
- Compared with Whites, all other racial and ethnic groups were more likely to report that home health care providers asked to see all the medicines they took.
- Asian, Native Hawaiian and Other Pacific Islander, multiple-race, and Hispanic adult home health care patients were less likely than White patients to report that home health care providers always seemed informed about all the care they got at home.
Care for Children With Special Health Care Needs
Addressing questions on access to and quality of care for children with chronic conditions is difficult due to the low prevalence of most conditions in children. A standard definition of CSHCN was developed in 1995. This definition was subsequently used to develop the CSHCN Screener Questionnaire and was included in the National Survey of Children With Special Health Care Needs, among other surveys.
According to the 2009/10 National Survey of Children With Special Health Care Needs, approximately 11.2 million children, or 15.1% of the population ages 0-17, were identified as having a special health care need. The Maternal and Child Health Bureau defines CSHCN as those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.
Having greater health care needs makes CSHCN susceptible to cost, quality, and access weaknesses in the health care system. Because they need more medical care, CSHCN have higher medical expenses, on average, than other children. For more than one in five CSHCN, costs of care caused financial problems for their families. According to the Medical Expenditure Panel Survey, the most commonly treated conditions of childhood in 2008 were acute bronchitis, asthma, trauma-related disorders, otitis media (middle ear infection), and mental disorders. A total of $32.9 billion was spent on these top five conditions.
In addition to facing financial burdens, families of CSHCN spend considerable time caring for them. An estimated 9.7% of CSHCN had families who spent 11 or more hours per week providing or coordinating care in 2005-2006 (HRSA, 2008). Studies have documented that children with chronic conditions in poor families and racial and ethnic minority groups may experience lower quality care.
Children with chronic conditions are reported by their parents to be less likely than other children to receive the full range of needed health services. Among CSHCN, minorities are more likely than White children to be without health insurance coverage or a usual source of care.
Figure 7.5. Effective care coordination among children with special health care needs, by age, insurance status, and income, 2009-2010
Source: Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health Web site, using the 2005/06 and 2009/10 National Survey of Children With Special Health Care Needs.
Denominator: CSHCN who were reported to use more than one service during the survey period.
- In 2009-2010, the percentage of CSHCN who had effective care coordination was higher for children ages 0-5 than for children ages 6-11 and 12-17 (58.8% compared with 54.9% and 55.5%, respectively; Figure 7.5).
- In 2009-2010, the percentage of CSHCN who had effective care coordination was higher for children with private insurance compared with children with public insurance only, private and public insurance, and no insurance (60.8% compared with 51.4%, 53.1%, and 37.7%, respectively).
Also in 2009-2010, the percentage of CSHCN with effective care coordination was higher for high-income children than for middle-income, low-income, and poor children (61.2%, 57.4%, 52.1%, and 51.6%, respectively).
Figure 7.6. Children with special health care needs with a medical home, by age, insurance, and income, 2009-2010
Source: Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health Web site using the 2005/06 and 2009/10 National Survey of Children With Special Health Care Needs.
Denominator: Civilian noninstitutionalized population ages 0-17 with special health care needs. Medical home outcome is defined by having at least one personal doctor or nurse; family-centered care in previous 12 months; no referral problems; usual source or sources of sick and well care; and received effective care coordination.
- In 2009-2010, the percentage of CSHCN who had a medical home was higher for children ages 0-5 compared with children ages 6-11 and 12-17 (44.2% compared with 42.1% and 43.1%, respectively; Figure 7.6).
- In 2009-2010, the percentage of CSHCN who had a medical home was higher for children with private insurance compared with children with public insurance only, private and public insurance, and no insurance (51.2% compared with 34%, 35.3%, and 24.2%, respectively).
- Also in 2009-2010, the percentage of CSHCN with a medical home was higher for high-income children than for middle-income, low-income, and poor children (52.2%, 47.4%, 37.5%, and 30.9%, respectively).
Health Resources and Services Administration, Maternal and Child Health Bureau. National Survey of Children With Special Health Care Needs Chartbook 2005-2006. Rockville, Maryland: U.S. Department of Health and Human Services; 2008. Available at: http://mchb.hrsa.gov/cshcn05/NF/7impact/time.htm
Shojania K, McDonald K, Wachter R, et al. Closing the quality gap: a critical analysis of quality improvement strategies—Volume 7: Care coordination. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Available at: http://www.ahrq.gov/clinic/tp/caregaptp.htm. Accessed September 12, 2013.
i For more information, go to http://hab.hrsa.gov/abouthab/special/underservedcommunities.html.
ii Available at: http://www.ahrq.gov/workingforquality/reports.htm.
iii The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, New Hampshire, New Jersey, and Utah.
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