Care Coordination Overview Janet Tennison, PhD UPV Standards October 8, 2013
What IS Care Coordination? The deliberate, proactive organization of patient care activities between two or more participants (including the patient). Care Coordination is a proactive; highperformance approach that fills in care gaps by ensuring patients care is planned, organized, and continuously monitored. US Department of Health & Human Services. Report to Congress: National strategy for quality improvement in health care;2011. Retrieved From HHS Website http://www.healthcare.gov/center/reports/quality032120.
The Need for Care Coordination Patients expect PCP to be aware of all their health-related activities, and to be involved Care being provided by more and more providers besides PCP making the care team much bigger Care is often provided in silos, without effective communication or collaboration
Referrals Rates Have Doubled (1999-2009) Typical PCP coordinates with 229 other providers in 117 practices 1 Average Medicare beneficiary sees 7 different providers from 4 practices and fills upwards of 20 RX s per year 2 Specialist visits account for more than half of all outpatient provider visits 3 1. Pham et al. Primary care physicians links to other physicians through Medicare patients: The scope of Care Coordination. Annals of Internal Medicine;2009; 150:236-242. 2. Chronic Conditions: Making the Case for Ongoing Care Partnership for Solutions, Partnership for Solutions, Johns Hopkins Univ. 2002. 3. Expenses for office-based physician visits by specialty, 2004, Machlin and Carper, AHRQ, 2007.
Traditional Referral Management? PCP faxes referral to specialist Provider asks MA to call specialist for urgent appointment Specialist is on vacation for 2 weeks Specialist calls patient and makes appointment Provider reviews EHR for specialist report MA calls another specialist for appointment Patient no-shows Patient visits PCP in 6 months with worsening symptoms Specialist calls patient and makes appointment
Coordination--Why Else Do We Need It? Determine patients goals Assist those high-risk patients who have been unsuccessful at managing their own care Engage patients to improve their self-care Improve the exchange between providers, patients, community services
Care Coordination is HOT Meaningful Use NCQA recognition National Quality Strategy IHI, AHRQ and other national agencies Improved patient experience, provider satisfaction Improved care quality, population health Decreased costs
Care Coordination in PCMH
The Medical Neighborhood
Common PCMH Elements Identifying and managing patient populations (High-risk, vulnerable) Planning and managing care (Pre-visit planning, shared decision-making) Tracking, coordinating, following-up on care (Closing referral loops, contacting facilities) Measuring and improving performance (metrics) Supporting self-care and promoting engagement (identifying care barriers)
NCQA Care Coordination Standards PCMH 5: Track and Coordinate Care (18 points) The practice systematically tracks tests and coordinates care across specialty care, facilitybased care, and community organizations. Element A: Test tracking and Follow-up (6 points) Practice has documented processes for: - Lab tests until results are available; flagging and following-up on overdue tests; electronically communicates to order/retrieve results
NCQA (Continued) Element B: Referral Tracking and Follow-Up (6 points MUST PASS) Practice coordinates referrals by: - Giving specialist clinical reason for referral and pertinent information; tracking the status of referrals; establishing and documenting agreements with specialists in the medical record if co-management needed