Background: Ongoing Efforts in Care Coordination and Gaps in the Evidence

Kathryn M McDonald; Vandana Sundaram; Dena M Bravata; Robyn Lewis; Nancy Lin; Sally A Kraft; Moira McKinnon; Helen Paguntalan; Douglas K Owens

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.)

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).

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2Background: Ongoing Efforts in Care Coordination and Gaps in the Evidence

Given the fragmented nature of the U.S. healthcare system, healthcare providers have increasingly implemented programs aimed at coordinating the care patients receive. Although these programs vary widely in structure and style, the primary goals of care coordination programs—to improve disease outcomes while containing overall healthcare costs—tend to be consistent across organizations. Historically, most care coordination programs have targeted patients with chronic conditions, which are costly, especially if managed poorly. According to a 2004 Partnership for Solutions report, 48% of the U.S. population has one or more chronic conditions; all their care represents 83% of total healthcare spending.¹⁴ Patients with chronic conditions visit their health care providers, fill prescriptions, and are hospitalized more often than the general population.¹⁴ Furthermore, patients with chronic conditions are more likely to experience poorly coordinated care, which can lead to adverse drug interactions, unnecessary or duplicate tests or procedures, conflicting information from multiple providers, and increased health care costs.¹⁴

These issues have challenged care providers, health system designer, policymakers and the research community for many years, though pressures have mounted in recent years with changing demography and patterns of illness (from more acute orientation to chronic care). Traditionally, coordination interventions follow from several perspectives: medical versus social; short-term episodic or acute care versus chronic and long term care; and various points of access to the patient (e.g., patient targeting to find those in need of high intensity services, managed care organization, or physician office practice). In the 1980's the National Long term Care Demonstration Project, a large scale randomized control trial of community care which tested channeling patients at risk of deteriorating and needing nursing home care into enriched models of community care based on case management and varying levels of authority and financial incentives.¹⁵ This project, commonly referred to as “Channeling” found that risk prediction was problematic in some cases, there was no benefit in terms of cost or clinical outcomes, and increased caregiver satisfaction.^16, ¹⁷ This project exemplifies the need to test complex interventions because findings are not always as expected. This study as well as other prominent work in the 1980's and 90's (especially the Social Health Maintenance Organization (S/HMO) Projects^18, ¹⁹ and the Program of All-Inclusive Care for the Elderly (PACE^20, ²¹)) also provided important lessons about linking medical and social models flexibly in order to achieve care coordination. Although the temptation in studying care coordination is to restrict the scope, historical experience demonstrates a need to consider interactions between separate systems of care (e.g., acute, community, long-term).

In the more recent past, care coordination programs initially gained a stronghold in the private sector, where managed care organizations, commercial vendors, academic medical centers, and private health insurers sought to implement coordinating mechanisms aimed at controlling costs, improving disease outcomes, quality of care, and patient satisfaction.²² Public sector programs, such as Medicare and Medicaid, followed suit with a series of congressionally mandated demonstration and pilot projects to test the efficacy of care coordination and disease management programs.

The goal of this chapter is to provide an overview of ongoing efforts in care coordination and key gaps in the evidence about the effectiveness of care coordination efforts. In the sections that follow, we first describe ongoing care coordination programs and related activities. Then, we present key questions related to the mechanisms and aims of care coordination of concern to health professionals. Finally, we highlight key gaps in the care coordination evidence-base.

Our approach to collecting the information presented in this chapter relied on background literature searches for policy papers, Internet searches using care coordination and related terminology for ongoing care coordination programs and demonstration projects, searches for conference brochures, and personal contacts with professionals currently leading care coordination efforts. This search was not intended to be exhaustive or fully systematic.

2A. Care Coordination Vendors

In the past decade, there has been a dramatic increase in the number of commercial companies selling care coordination services to healthcare providers. Many of these refer to their services as disease management or care management. The revenue associated with the sale of disease management services has increased more than ten-fold, from $78 million in 1997 to $1.2 billion in 2005.²³ Initially, disease management vendors tended to focus on a small number of chronic conditions, but more recently some of the larger companies have extended their services to cover more than 120 conditions.²³ These trends relate to outsourced disease management, and thus do not necessarily reflect disease management practices set up internally by some health care providers. The market has also expanded in terms of the types of providers of these services, including health plans, pharmaceutical companies, pharmacy benefit management companies, disease management companies, and even health and information companies selling specific disease management tools (e.g., physician alerts, 24-hour call centers, educational material, care monitoring software, etc.). While the industry has traditionally focused on physical health conditions, the public sector demands for integration and efficient resource use for mental health and substance abuse disorders have encouraged new roles for managed behavioral health organizations.²⁴

Perhaps one of the biggest issues facing care coordination vendors, and the field at large, is how to best measure and evaluate the effectiveness of their programs. Evaluators are interested linking specific components of care coordination and intensity of intervention (e.g., number of contacts, caseloads) to outcomes. Organizations, such as the Disease Management Association of America (DMAA), are currently working to develop standardized disease and care management measures. Other groups, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Utilization Review Accreditation Commission (URAC), and the National Committee for Quality Assurance (NCQA) have initiated accreditation and certification programs for disease management programs. Efforts to evaluate effectiveness and efficiency are widespread, although the evidence from the peer-reviewed literature describing these efforts is mixed.²⁵ In general, vendors report positive return on investment (ROI) numbers, though buyers have expressed concern about biased methods and a lack of comparability across ROI analyses.²⁶–²⁸ Observers of the field have also voiced concerns about relying on potentially out-of-date findings from projects conducted in a dynamic health plan environment.^29, ³⁰

2B. Purchasers and Developers of Care Coordination Programs

Medicare

Twenty-three percent of Medicare beneficiaries with five or more chronic conditions account for 68% of total Medicare spending.³¹ The care these individuals receive is often fragmented across settings and providers, with many providers failing to follow evidence-based guidelines and with patients not well versed in self-care management strategies.²² This lack of coordination often results in poor clinical outcomes, repeated hospitalizations, excessive utilization of prescription drugs, medical errors, dissatisfaction with care, and higher costs to the Medicare program.^32, ³³

In response to this association between poorly coordinated care among Medicare beneficiaries with multiple chronic medical conditions and poorer outcomes of care, the Balanced Budget Act of 1997 mandated a coordinated care demonstration study for chronically ill fee-for-service Medicare beneficiaries.³² To determine the best practices in coordinated care and assess how best to structure the demonstration project, the Centers for Medicare & Medicaid Services (CMS) commissioned a report from Mathematica Policy Research, Inc. (Princeton, New Jersey) that examined existing care coordination schemes and proposed design options for future demonstration projects. Their 2000 report, entitled, “Best Practices in Coordinated Care,”³² made the following five recommendations:

1.: "Programs should follow the three steps: Assess and Plan, Implement and Deliver, and Reassess and Readjust for all enrolled patients;
2.: Programs should have express goals of prevention of health problems and crises, and of early problem detection and intervention;
3.: Disease-specific programs should incorporate national evidence-based or consensus-based guidelines into their interventions;
4.: Care coordinators should be nurses with at least a bachelor's degree in nursing; and
5.: Programs should have significant experience in care coordination and should have evidence of having reduced hospital use or total medical costs."³²

Since the publication of this report, CMS has funded a number of care coordination and disease management demonstration projects designed to improve health outcomes without increasing costs. These projects have typically emanated from legislative mandates. For example, Congress established the Chronic Care Improvement Program (since termed Medicare Health Support) in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Public Law 108–173; section 721)^34, ³⁵ to test new incentives and approaches for improving care coordination for elders with high cost complex and chronic illnesses. We have provided a brief description of several Medicare care coordination demonstration projects in Table 1 and direct the interested reader to the Medicare Demonstration Projects Evaluation Web Site³⁶ for additional information and future updates.

Table 1

Recent Medicare demonstration and pilot projects with care coordination elements.

Medicare has implemented a variety of care coordination projects that differ in design and are currently in varying stages of implementation. At the time of publication of this report, however, comprehensive and finalized results of these demonstrations were not available. Similarly, specific details about financial arrangements and actual implementation experience are not generally available. Within the next one to three years additional information about the demonstration experiences, cost effectiveness, patient and provider satisfaction, and general effectiveness of care coordination programs within the Medicare system should be available.

State Medicaid Programs

Medicaid beneficiaries with chronic conditions account for more than three-quarters of current Medicaid spending.⁴⁵ State Medicaid programs have increasingly utilized care coordination programs in an effort to contain costs and better meet the needs of beneficiaries. The focus of most Medicaid programs, which have been implemented through vendors, has been on patient self-management support and nurse case-management.

According to a 2004 Kaiser Family Foundation survey of Medicaid directors, states have increasingly implemented disease management programs to contain costs for patients with chronic or disabling conditions.⁴⁶ Between 2002 and 2005, 42 states began a disease or case management program.⁴⁶ Additionally, state Medicaid programs have trended towards broader disease management programs that are not defined by specific conditions to help manage patients with multiple chronic and complex conditions.⁴⁷ The key findings of the survey of Medicaid directors' impressions indicate that disease management programs appear to lead to cost savings, and that carefully designed disease management programs, which go beyond teaching self-care principles to address the underlying infrastructure of care, have potential for the most success.⁴⁷

Across the U.S., state Medicaid programs vary in terms of their approaches to care coordination. For example, the 2004 report by the National Pharmaceutical Council identified four methods of delivering disease management to Medicaid recipients with asthma:

1.: "Medicaid health outcomes partnerships are usually applied to an existing fee-for service primary care case management program. Medicaid programs focus on high-priority diseases, offering a number of support systems to help existing Medicaid providers better serve the patients assigned to them;
2.: Disease management organizations are outside contractors who are retained by the state to address particular diseases, either by supplementing existing Medicaid providers and their case management activities or by taking over responsibility for targeted patients;
3.: Pay for performance approaches establish new rules for scope of practice or referrals and involve nontraditional providers in the care of patients with specific diseases. The nontraditional providers are paid a special fee contingent on improving health outcomes or lowering costs;
4.: Centers of excellence focus on particular disease episodes for high-cost, high-volume diseases and select a network of hospitals, physicians, and other providers who are already organized to receive a prospective, bundled payment per episode of care."⁴⁸

The January 1, 2006 implementation of Medicare Part D prescription drug benefit has resulted in some new concerns for the coordination of pharmaceutical coverage for some Medicare and Medicaid recipients. Under the new Part D program, beneficiaries dually eligible for both programs will no longer be able to secure their prescription drug coverage through Medicaid and will be expected to enroll in a Medicare prescription drug plan, although there is uncertainty about whether they will receive equivalent coverage. A large proportion of chronically ill Medicaid patients are dually eligible, and state Medicaid officials are concerned that current disease management strategies may not be sufficient in the face of these changes.⁴⁹

We have provided a brief description of several Medicaid care coordination projects in Table 2 and direct interested readers to their website³⁶ for case studies of ongoing disease management efforts among states.

Table 2

Medicaid research projects with elements of care coordination.

Although we have highlighted several Medicaid programs and studies, publicly available research is somewhat limited on the effectiveness of disease management in Medicaid populations. While several modes of delivering care coordination exist, it is difficult to state with certainty whether these programs are effective. Research in this sector appears promising, but there is a need for more in-depth evaluations of state Medicaid disease management programs.

Department of Veterans Affairs

In 2003, the Department of Veterans Affairs (VA) established the Office of Care Coordination to support the implementation of a nationwide care coordination program. This effort is in addition to ongoing coordination activities (geriatrics evaluation and management units, coordinated spinal cord injury centers, aging interventions, integrated HIV care, etc), which are not covered further in this section. The VA's care coordination efforts (through the centralized office) focus on the use of appropriate information technologies to connect patients to healthcare services within the VA. Telehealth technologies, supported by the VA's existing computerized medical record system, are being used to help ensure that patients receive “the right care at the right time.”⁵³ Specifically, telehealth is expected to reduce clinic visits, improve access to care, help avoid the cost and hassle of travel to distant VA facilities, enhance patient satisfaction, and be more cost efficient compared to usual care.⁵³

At present, the VA has initiated three telehealth care coordination systems. First, the Home Telehealth system allows patients to connect with providers from their homes. This program is targeted at patients with conditions that can impair their ability to make frequent office visits, such as diabetes, chronic heart failure, chronic obstructive pulmonary disease, post traumatic stress disorder, depression, and spinal cord injury. All patients involved with the VA's Care Coordination/Home Telehealth (CCHT) programs are supported by a care coordinator, who can be a physician, but is usually a registered nurse, a nurse practitioner, or a social worker.⁵⁴ Care coordinators manage between 90 and 150 patients, depending on the complexity of the patient population.⁵⁴ As of September 2005, almost 9,000 patients were enrolled in CCHT care, with 21,000 to 25,000 expected to be enrolled in September of 2006.⁵⁴

Second, the General Telehealth system allows patients to connect with remote specialists via telehealth technologies within a VA clinic. The principal areas of interest for this program are telemental health, telerehabilitation, teleendocrinology, and telesurgery. Third, the Store-and-Forward approach to digital imagery enables digital images to be obtained and reviewed by a specialist remotely. This approach is common in the fields of radiology, dermatology, and retinal imaging—especially for patients with diabetes.⁵³

According to the May 18, 2005 congressional testimony of Patricia S. Ryan, the Director of the Community Care Coordination Service in Veterans Integrated Service Network 8, patient satisfaction with the care coordination process as well as ease in use of the telehealth technology was above 95% for the past several years.⁵⁵ A non-randomized study of a CCHT program for diabetes showed a reduction in hospitalizations, emergency room use, and the average number of bed days of care, and improvements with respect to health-related quality of life.⁵⁶ Other recent studies of the VA's telehealth care coordination efforts, including those with more rigorous designs, report favorable results in terms of patient and provider satisfaction,^57, ⁵⁸ utilization (including reductions in primary care visits initiated by a care coordinator,⁵⁹ bed days, and urgent visits),⁶⁰ clinical outcomes,⁶¹ and cost.⁶⁰

Other Federal Programs

The U.S. Congress passed the Patient Navigator Outreach and Chronic Disease Prevention Act of 2005, and the President signed the bill on June 29, 2005, to authorize the Secretary of the Department of Health and Human Services—through the Administrator of the Health Resources and Services Administration, and with participation of the Indian Health Service, the National Cancer Institute, the Office of Rural Health Policy—to make grants for the development and operation of demonstration programs to provide patient navigator services to improve health care outcomes.⁶² Two of the roles stated for a patient navigator by the legislation explicitly involve coordination: 1) assisting in the coordination of health care services and provider referrals, for individuals who are seeking detection services or follow-up for cancer or other chronic disease; and 2) coordinating with the health insurance ombudsman programs to address coverage needs. The legislation authorized appropriations of $25 million over five years starting in fiscal year 2006.

Another recent national effort to enable care coordination (among other improvements to the health care delivery system) took the form of an executive order: “Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator.”⁶³ To provide leadership for the development and nationwide implementation of an interoperable health information technology infrastructure that does not rely on federal funding, but rather develops through collaboration between public and private interests, the President ordered a new position within Health and Human Services, “The National Health Information Technology Coordinator (National Coordinator).” The policy directive to the Coordinator specifies development of “an effective infrastructure for the secure and authorized exchange of health care information” that “improves the coordination of care and information among hospitals, laboratories, physician offices, and other ambulatory care providers.”

Private Sector Developers and Purchasers

In 2002, a survey found that nearly 90% of healthcare systems and managed care organizations reported they had or were developing disease management programs.⁶⁴ Health insurers and integrated systems are among the biggest customers of care coordination and disease management vendor services. Expanded coverage of drugs by Medicare has led pharmacy benefits management firms to work with disease management vendors in product offerings to the private sector.⁶⁵ These same organizations sometimes develop their own disease-focused coordination programs. Recently, reports about obesity management have indicated that health insurers are certifying centers of excellence for bariatric surgery, and playing a patient channeling and coordinating role themselves.⁶⁶ Some integrated health systems, such as Kaiser, have in-house care management programs⁶⁷ that they have developed. Other groups have developed their own programs for the Medicare Coordinated Care Demonstration, including one integrated delivery system (Carle Foundation), four hospitals or academic medical centers, one hospital consortium, a retirement community, a long-term care provider and a hospice. The other six organizations in this demonstration are working with care coordination providers (outsourcing services).⁴²

2C. Professional Specialty Associations

Specialty associations, representing the diverse views of physicians, nurses, pharmacists, patients, and care management advocates have increasingly developed policy statements regarding key aspects of the care coordination debate. Physician groups, such as the American Academy of Pediatrics,⁶⁸ the American Academy of Family Physicians (AAFP),⁶⁹ the American College of Physicians (ACP),⁷⁰ the Society of General Internal Medicine (SGIM),⁷¹ the Society for Primary Care,³³ and the American Geriatric Society (AGS)⁸ generally support care coordination efforts and have even advocated financial incentive programs for physicians performing coordination tasks. In his 2004 testimony, before the Practicing Physicians Advisory Council, Thomas J. Weida of the AAFP called for a care management reimbursement fee for patients with chronic conditions stating that, “Effective chronic care management involves developing a partnership with each patient, developing a care plan, ongoing communication and coordination of disparate systems to integrate their care, patient education resources and delivery systems, and more. This consumes additional physician time and resources and requires different models of delivering care.”⁷² Similarly, Robert Berenson of the Urban Institute, in his 2004 congressional testimony, advocated physician reimbursement for chronic disease care management and criticized Medicare's current approach as a “corporate one, focused on providing contracts to third-party vendors, rather than directly enabling professionals to better serve their patients.”⁷³ Recently, the ACP published a policy monograph on “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care” that calls upon fundamental changes to the health care system, where “physicians are once again partners in coordinating and facilitating care to help patients navigate the complex and often confusing health care system by providing guidance, insight and advice in language that is informative and specific to patient needs.”⁷⁴

Other specialty groups, such as the American Psychological Association and the American Academy of Pediatrics Council on Children with Disabilities, have highlighted the unique care coordination needs of children and adolescents with mental health issues and other special needs. A 2005 Society of Primary Care policy paper entitled, “Healthy, Wealthy and Wise: Expanding the Medical Home,” proposed the development of centers that would coordinate and integrate a host of medical and social programs, such as disease management, case management, home visits, financial and debt management, exercise programs, and life skills training to vulnerable populations.⁷⁵

Groups like the Disease Management Association of America (DMAA) and Case Management Society of America (CMSA) are also working to bring attention to their causes. The DMAA is undertaking research efforts involving the standardization of disease management definitions, the standardization of outcomes evaluation metrics, and the development of a disease management patient and provider satisfaction measurement tools, among other activities. They have also recently published a dictionary of disease management terminology and a guide to disease management program evaluation, both of which are tools to help examine disease management program performance.⁷⁶ Likewise, the CMSA also works to shed light on the importance of case management by educating healthcare consumers, providers, payers, and regulators.⁷⁷

2D. Patient and Family Associations

Patient advocacy groups have also taken a keen interest in care coordination activities. The Palliative Care Policy Center's Care Coordination Coalition put forth recommendations at the 2005 White House Council on Aging, which included paying for physician's care coordination services and ensuring continuity of patient records across settings and time.⁷⁸ At a 2002 conference supported by the Commonwealth Fund, the Center for Medicare Advocacy also developed a set of recommendations for a Medicare coordinated care benefit, which called for improved care but not reduced costs to be the primary goal of services to patients and advocated the use of a care coordinator to oversee the health and social services for patients.⁷⁹

Caregiver alliances, such as the National Family Caregivers Association and the National Alliance for Caregiving, also highlight the role of caregivers as care coordinators, and even provide information about services offered by independent caregivers.⁸⁰

2E. Conferences

There has been a proliferation of conferences providing an opportunities to discuss contemporary issues in care coordination.⁸¹–⁸⁴ For example, the 2002 Aspen Transitional Care Conference sought to explore reasons for failures to appropriately provide transitions in care between settings, to define the responsibility for care transitions for health professionals, and to develop a research agenda for interventions designed to evaluate and improve transitional care.⁸² The seventh annual conference of The Disease Management Association (DMAA) discussed the standardization of disease management measures and processes to evaluate both clinical effectiveness and return on investment.⁸⁵ Other organizations across the public and private sectors held care coordination conferences or workshops in 2006 (Table 3).

Table 3

Example conferences in 2006 with care coordination themes.

The themes of these conferences suggest a growing interest in the many dimensions of care coordination programs, as health care decisionmakers strive to gain a better understanding of conceptualizing, implementing, measuring, and evaluating coordination processes.

2F. Other Activities Described by Care Coordination Professionals

Through a series of Internet and literature searches using care coordination terminology, we identified and spoke with professionals actively involved in care coordination efforts to learn more about the key issues facing the field. Our professional contacts ranged from people involved with federal efforts to implement care coordination programs to private sector disease management companies, policy institutes that work with State Medicaid directors, health provider organizations, health plans, academic researchers, foundations, specialty advocacy group representatives, and clinical professional organizations. Through our conversations with care coordination professionals, we aimed to identify critical areas of controversy and common interest in the field, and the key gaps in the care coordination evidence base.

Questions of Interest to Care Coordination Decisionmakers

Defining and Conceptualizing Care Coordination

How should care coordination be defined?
How can care coordination be conceptualized for purposes of implementation and evaluation?
How do various professions (e.g., nurses, physicians, hospice and social workers) understand care coordination? What are the similarities and differences in their points of view?

Structuring Care Coordination Programs

What would the optimal care coordination program look like?
How to coordinate care for multiple chronic conditions?
What existing systems do you need in place for care coordination to be most effective?
How to increase access to care coordination schemes?
How to apply a care coordination model to every day people, not just those with high risk, chronic conditions?
How do you best train people to do care coordination? What is the ideal training/skill set/caseload?
What is the role of information technology in care coordination?
Who should pay for care coordination? What financial incentives are needed?

Coordination Settings

Where in the care continuum is coordination most likely to break down?
How to coordinate care across settings?
How to coordinate care that falls outside of traditional healthcare setting, such as consumer directed healthcare purchases, and work and school based management programs?
What care coordination program will work best in my setting (or across settings that my organization might influence)?

Patient Groups To Target

Which patient groups would benefit most from care coordination?
Which patient groups are most likely to have poor coordination experiences?
How does care coordination vary by disease, race, and/or age of the population?

Provider and Patient Roles

What should be the patient's role in a given care coordination scheme?
How does care coordination differ according to the health care provider's role? Is what a physician does to promote care coordination different from what a nurse does?
Who is responsible for coordinating care of a complex patient who is managed in multiple settings by multiple providers?
What's the best provider skill mix to make care coordination happen? What methods work to obtain buy-in for coordinating care from usual care physician?
How do recent efforts in pay for performance and consumer driven health care influence respectively provider and patient coordination responsibilities?

Assessing Care Coordination

How should care coordination be measured?
How much do care coordination programs cost? Are they cost effective?
What outcomes should be measured to ascertain if care coordination is making a difference? Over what period of time?
Does care coordination lead to decreased hospitalization and repeat testing?
Will care coordination demonstrate a return on investment? What methods are appropriate to measure return on investment?
Will people be less sick if care coordination is implemented?
Is coordinating care better than doing nothing?
Are patients more satisfied with care when it is coordinated better?
Is care coordination more apt to increase the timeliness of care?
What is the impact of care coordination on caregivers? Are caregivers satisfied and does it help?
What is the relationship between the way care coordination is structured and its effectiveness?
Does the degree of a health plan's integration affect how well care coordination works?

Key Gaps in the Care Coordination Evidence Base

Measures

Care coordination metrics to measure if coordination is occurring and how it is working.
Metrics for calculating costs and savings associated with care coordination.

Evidence

Evidence on the efficacy of care coordination.
Identification of best practices for care coordination.
Guidelines for coordination of care of patients with multiple chronic conditions.
Research on care coordination as it pertains to patients with chronic conditions.
Relative effectiveness of integrated, practice-centered approaches versus “carve out” approaches (e.g., vendor supplied disease management or external case management).

Conceptual Frameworks

A consensus definition of care coordination.
Common terminology/vocabulary for describing and evaluating care coordination.
A model for implementing and evaluating care coordination.
Framework for describing and relating the elements of care coordination.
Different considerations and needs depending upon perspective (e.g., broad systems level perspective with responsibility for longitudinal, population-based care versus health care delivery perspective concerned with managing handoffs between care providers).
Research models on how best to coordinate care for specific healthcare settings and patient populations.
A model of communication that will allow diverse provider groups to better interact.

Other

Effects of widespread use of electronic medical record to help facilitate coordination.
Caregivers role in care coordination schemes.
Effects of reimbursement for performing care coordination tasks.
Effects of improved integration across specialties.

2G. Summary Answers to Key Questions

Research Question 1: What Aspects of Care Coordination Are of Greatest Interest to Healthcare Decisionmakers?

Among health professionals, the lack of a care coordination definition and conceptual model were key areas of concern. These deficiencies were considered barriers to effectively evaluating and assessing care coordination processes. Additional evidence regarding the influence of care coordination programs on health, cost, and satisfaction outcomes was also frequently noted. Many decisionmakers wanted to know if care coordination actually worked, and, if so, how it affects costs. Furthermore, those with responsibility for managing health care sought answers for what approaches to care coordination were likely to work, under which circumstances (e.g., by disease, setting, geographical region, payor), and for which patient populations. Finally, of interest to all decisionmakers, was the development of measures and approaches to examine the effectiveness and quality of care coordination interventions.

Research Question 2: What Are the Key Gaps in the Care Coordination Evidence Base?

The care coordination field would benefit from consensus definitions, conceptual models, and measures of care coordination processes. However, the dearth of evidence surrounding the efficacy and cost-effectiveness of various care coordination programs are also pressing issues facing decisionmakers. They want practical answers about what to implement to improve care coordination, and yet the field is only just emerging as an area of concerted study from a conceptual as well as a pragmatic perspective. Additionally, the private sector is playing a major role in providing care coordination services, yet specific details about the extent and the effectiveness of their programs is not generally available to the public.

Bookshelf ID: NBK44011

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