Ongoing Efforts in Care Coordination and Gaps in the Evidence (Chapter 2)

• What aspects of care coordination are of greatest interest to healthcare decisionmakers?
• What are the key gaps in the care coordination evidence base?

Definitions of Care Coordination and Related Terms (Chapter 3)

• What definitions exist for care coordination?
• What definition could be formulated to apply to systematic reviews?

Review of Systematic Reviews of Care Coordination Interventions (Chapter 4)

• Which care coordination interventions have been evaluated by systematic reviews and how were they defined?
• What is the evidence regarding the health benefits of these care coordination interventions as summarized in the systematic review(s)? In particular, is the effectiveness of care coordination interventions related to the setting in which care is being coordinated, the component of care being coordinated, or the type of disease or patients for whom care is being coordinated?
• Have the costs of care coordination interventions been evaluated in any of these systematic reviews, and if so what is known?

Conceptual Frameworks and Their Application to Evaluating Care Coordination Interventions (Chapter 5)

• What concepts are important to understand and relate to each other for future evaluations of care coordination? What conceptual frameworks could be applied to support development and evaluation of strategies to improve care coordination?
• What measures have been used to assess care coordination?
• How do these frameworks relate to quality improvement strategies evaluated in the previous Closing the Quality Gap series reports?

Ongoing Efforts in Care Coordination and Gaps in the Evidence (Chapter 2)

Background literature review, Internet searches, and personal contacts were used to find policy papers, conference brochures and information about ongoing care coordination programs, demonstration projects, and gaps in the evidence base.

Definitions of Care Coordination and Related Terms (Chapter 3)

Iterative searches of PubMed^®, CINAHL^® and Health and Psychological Instruments (HaPI) databases were supplemented with the information gathered for Chapter 2 to identify sources with definitions of care coordination and related terms.

Review of Systematic Reviews of Care Coordination Interventions (Chapter 4)

We searched MEDLINE^® (through September 30, 2006), CINAHL^®, Cochrane database of systematic reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, PsychInfo, Sociological Abstracts and Social Services Abstracts (these databases searched through November 15, 2006) for systematic reviews of care coordination interventions to improve quality of care provided to patients.

Included Studies. English language systematic reviews of care coordination interventions, irrespective of clinical condition, patient population, or specific outcomes were included. Systematic reviews of interventions occurring solely in the hospital setting were excluded because findings would not be relevant to care across the continuum for those with chronic illnesses, a primary focus of the IOM's prioritization of care coordination. Interventions where the only two participants were a clinician and the patient were excluded because these situations presumably have lower demands for coordination activities. Articles were included if they reported any evaluation metrics.

Data Abstraction. From each of the included reviews, data were abstracted about whether the entire focus of the review was on care coordination or only a partial focus was on care coordination. For those reviews where the entire focus was on care coordination, abstracted data included: the research methodology used, setting of the care coordination intervention, terms and definitions used to describe the care coordination intervention, quality assessment variables, and the reported outcomes, including clinical outcomes, health services utilization, cost, cost-effectiveness, and quality of life. For those reviews which only partially focused on care coordination, we abstracted data about the purpose of the review, the care coordination strategies included, and outcomes.

Statistical Analysis. Results reported in the systematic reviews were reported separately and not synthesized quantitatively given the heterogeneity of the included articles. Narrative analysis was conducted.

Conceptual Frameworks and Their Application to Evaluating Care Coordination Interventions (Chapter 5)

We used articles identified in the Chapter 3 search to identify literature describing conceptual frameworks and associated empirical evidence related to care coordination. We also reviewed the theoretical work developed in the behavioral, organizational, and health services research fields to select well-established frameworks relevant to care coordination with complementary concepts. We identified measures/scales related to care coordination and summarized their relationship to the frameworks.

Summary Answers to the Key Questions

Research Question 1: What Aspects of Care Coordination Are of Greatest Interest to Healthcare Decisionmakers? Health professionals raised concerns about the lack of a care coordination definition and conceptual model. They considered these deficiencies as barriers to effectively evaluating and assessing care coordination efforts. They also frequently expressed a need for additional evidence regarding the influence of care coordination programs on health, cost, and satisfaction outcomes. Many decisionmakers simply wanted to know if care coordination actually worked, and, if so, how it affects costs. Furthermore, those with responsibility for managing healthcare sought answers for what approaches to care coordination were likely to work, under which circumstances (e.g., by disease, setting, geographical region, payor, etc.), and for which patient populations. Finally, decisionmakers were keenly interested in 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 how to implement effective and efficient 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.

Research Question 3: What Definitions Exist for Care Coordination? The term, “care coordination,” is cited often in the health services literature, but is infrequently explicitly defined. We identified more than 40 definitions of coordination and they pertain to a diverse set of patient populations, healthcare scenarios, and organizational situations. While definitions vary depending on their purpose and audience, five common elements of care coordination were identified from our review of definitions and studies related to coordination:

1.

Numerous participants (including the patient) are typically involved in care coordination;

2.

Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient's care;

3.

In order to carry out these activities in a coordinated way, each participant needs adequate knowledge about their own and others' roles and available resources;

4.

In order to manage all required patient care activities, participants rely on exchange of information; and

5.

Integration of care activities has the goal of facilitating appropriate delivery of health care services.

Research Question 4: What Definition Could be Formulated To Apply to Systematic Reviews? We combined the common elements from many definitions to develop our following working definition, which we used to guide our review of systematic reviews on care coordination:

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.

Our working definition is purposely broad enough to include interventions that are sometimes defined by their own related terminology (e.g., disease management, case management, teamwork, collaboration, Wagner's Chronic Care Model and extensions). It is also applicable to programs, such as the Medicare demonstration projects to improve care for those with chronic illness. The objective of these interventions and programs is to improve quality of care, in part or in total by enhancing coordination between participants for the benefit of the patient (improved outcomes) and the system (reduced costs).

We also developed a list of components of care coordination (Table A) to support a more granular analysis of interventions. The components are separated into essential care tasks (e.g., identify participants and their roles), their associated coordination activities (e.g., coordinate among care plans), and common features of interventions to support coordination activities (e.g., standardized protocol, multidisciplinary team). The list draws extensively from components described by clinical professional organizations, recent consensus development efforts by the National Quality Forum, and intervention evaluators.

Research Question 5: Which Care Coordination Interventions Have Been Evaluated by Systematic Reviewers and How Were They Defined? Among our included reviews, we identified various care coordination interventions that have been evaluated. The terms used to define the care coordination strategies were highly heterogeneous. The 43 individual reviews that focused entirely on care coordination referred to 20 different care coordination interventions. The most common strategy evaluated the use of multidisciplinary teams involving two or more providers from different specialties providing care to a group of patients (15 reviews); the terms applied to this strategy included multidisciplinary teams, team coordination, assertive community treatment, collaborative care, integrated programs, and shared care. The next most common strategy evaluated was disease management (10 reviews). It was defined variably or not at all in the included reviews and there did not appear to be a consensus about the components that should be included in a disease management program; however, the intent of all the disease management programs reviewed was to improve the coordination of patient care, provide support to patients, and improve patient outcomes. Finally, nine reviews assessed the role of case management (also referred to as care management) which typically involves the assignment of a single person (case manager or “key worker”, so named in one study) who coordinates all aspects of a patient's care (e.g., providing information to multiple providers, seeing that the patient receives services in a timely manner etc.). The qualifications and exact duties of case managers were poorly described in most reviews. Other strategies evaluated were integration of care (three reviews), and interprofessional education, defined as the provision of training and education to professionals from different health and social areas, who learn together interactively (three reviews).

Research Question 6: What is the Evidence Regarding the Health Benefits of These Care Coordination Interventions as Summarized in the Systematic Review(s)? In Particular, is the Effectiveness of Care Coordination Interventions Related to the Setting in Which Care is Being Coordinated, the Component of Care Being Coordinated, or the Type of Disease or Patients for Whom Care is Being Coordinated? Among the 43 reviews that focused on care coordination interventions, and an additional 32 that included care coordination among other quality improvement approaches, the most common conditions targeted were mental health conditions (28 reviews), heart failure (14 reviews) and diabetes (seven reviews). Eleven reviews were not specific to any condition. Overall, the reviews reported a positive effect of the care coordination strategies on the outcomes studied, regardless of clinical topic. Multiple systematic reviews provided evidence of patient benefit resulting from multidisciplinary teams, disease management, and case management. Multidisciplinary team interventions improved service continuity for severely mentally ill patients (two reviews); reduced mortality and hospital admissions in heart failure patients (two reviews); reduced symptoms for terminally ill patients (one review); and reduced mortality and dependency in stroke patients (one review). Disease management programs reported improved depression severity and adherence to treatment in patients with mental illness (one review); reduced mortality and hospital admissions in heart failure patients (two reviews); and reduced glycated hemoglobin (one review) and improved glycemic control (one review) in patients with diabetes. Case management as a care coordination strategy appeared to improve re-hospitalization rates in patients with mental health problems (one review) and improved glycemic control in patients with diabetes (one review). While these and other care coordination interventions (e.g., integrated care, shared care, organized clinic) have been reported in systematic reviews covering other clinical areas such as rheumatoid arthritis, pain management, asthma and cancer, there is insufficient evidence to draw firm conclusions in these other instances.

Setting of Care. Interventions were conducted across different settings (home, community, outpatient clinic), with half of the reviews conducting interventions across multiple settings, an interface commonly noted as challenging for coordination of care. One review on heart failure reported that interventions with a home-based component or telephone follow-up were more effective than those based in the hospital or clinic, but there is little evidence to examine the effect of setting on the effectiveness of care coordination interventions. Furthermore, there was also insufficient evidence to determine the relative effectiveness of any particular care coordination intervention compared to others in improving patient outcomes across care boundaries.

Components of Care Coordination. Using a list of essential tasks of care for a patient, associated care coordination activities, and features to support the activities, we reviewed 15 recent systematic reviews to assess if the reviews provided any information on specific components of the care coordination intervention; 13 of these provided limited information. The descriptions of interventions presented in systematic reviews generally do not provide adequate information for complete categorization into components. The current evidence base does not support a granular, component-level analysis from systematic reviews.

Patient Population. Among our included systematic reviews, care coordination interventions were most frequently targeted at patients with mental health problems (multidisciplinary teams and case management being the main interventions evaluated in this population); heart failure and diabetes were the next most frequently studied conditions. The main interventions evaluated for heart failure were multidisciplinary teams and disease management and while the reviews were consistent in reporting improved outcomes associated with both these interventions, there was considerable overlap of the included studies across the reviews studying patients with heart failure. Care coordination interventions were also evaluated among a diverse group of clinical conditions (diabetes, asthma, heart condition, stroke, rheumatoid arthritis, cancer, pain management). Most of the reviews reported improved outcomes for each strategy; however, there was insufficient evidence that one particular strategy was more effective than others in improving outcomes.

Most of the included systematic reviews evaluated care coordination interventions in adults in the general population of patients from primary care or hospital settings. Eight of the reviews evaluated interventions among the elderly, a vulnerable group more likely to have poorly coordinated care. The findings from these reviews suggest that care coordination strategies may improve outcomes among elderly patients (specifically by decreasing hospital admissions); however, the heterogeneity of the included strategies do not permit any further synthesis that would allow us to assess the effectiveness of one particular strategy over another.

Summary. The overall quality of the included systematic reviews was very good, with most reviews providing detailed search terms, inclusion/exclusion criteria and appropriate synthesis of their included articles. Therefore, the generally positive findings for many of the interventions are encouraging, and offer health professionals and system level decisionmakers with a range of options to test in their own environments.

Research Question 7: Have the Costs of Care Coordination Interventions Been Evaluated in Any of These Systematic Reviews, and if so What is Known? Costs were evaluated in approximately half of the included reviews that focused solely on care coordination; however, only one of the reviews reported findings on the cost-effectiveness/cost-benefit of the care coordination intervention. The evidence from this review suggests that comprehensive disease management programs are cost-effective for improving outcomes in patients with depression. The remaining reviews provided some cost estimates of the interventions evaluated; however, the evidence was insufficient to allow for any definitive conclusions regarding the costs and benefits of the care coordination interventions evaluated. Some studies reported increased utilization of services for the coordination intervention group.

Research Question 8: What Concepts are Important To Understand and Relate to Each Other for Evaluations of Care Coordination? What Conceptual Frameworks Could be Applied To Support Development and Evaluation of Strategies To Improve Care Coordination? We identified four well-established frameworks that complement each other in terms of developing and studying care coordination interventions. Taken together, the frameworks include a dozen concepts generally fitting into one of three domains: baseline assessment of the specific patient care situation, coordination mechanisms, and outcomes of care.

These frameworks provide evaluators of new interventions with a guide to exploring the possible relationships and connections between an intervention and patient outcomes. Developers and evaluators of interventions to improve coordination need to ask:

• What are the coordination needs related to patient care?
• Who are the participants in care, and how are they dependent on each other for a given care situation)?
• What are the factors already in place that may facilitate care coordination (e.g., personnel resources, information systems)? How does the intervention interact with or involve these factors?
• What are the factors that influence the motivation of those involved in coordination (e.g., attitudes, incentives)?
• How is the intervention expected to change the key coordination processes of 1) getting the necessary information across interfaces, such as different settings of care (i.e., “informational exchange” from one theory), and 2) establishing an understanding of the relationship of one individual's work to the overall goals and to that of others involved in patient care (i.e., “relational awareness” from another theory)?
• How are the interactions of these factors and coordination processes expected to affect clinical processes and patient outcomes (e.g., what is the hypothesis about why the intervention will work)?

Research Question 9: What Measures Have Been Used To Assess Care Coordination? Studies of care coordination have evaluated patient outcomes, including changes in mortality, symptoms, unemployment, staying connected to services, and adherence to medication. Cost and utilization outcomes, including hospitalizations, emergency department visits, and clinic visits were included in a number of studies. Also, patient and family satisfaction were reported in some instances.

We also separately searched the literature for instrument development related to care coordination, and found 20 instruments and approaches. About half of the instruments are targeted at patient and family members, and ask about perceptions of care, including items about coordination (e.g., “treatment was planned with appropriate considerations of previous course of the disease”,^* “told me which nurse was primarily responsible for coordinating my care.”^** Two of the instruments derive their data from chart reviews to assess the information exchanged between physicians. Seven instruments survey physicians or members of a defined care team to assess collaboration and teamwork processes and performance. Two instruments evaluate resources and structures (e.g., community linkages) that support care coordination. One of these instruments is for systems that care for adults with chronic illness, and the other is for primary care practices that have adopted a “medical home” approach to pediatric care.

The measurement field related to care coordination is in the early phases of its development. It is as yet unclear what approach or combination of approaches to measurement will adequately capture the processes driving an intervention's effect, particularly outside well-defined care settings, where the challenges for coordination are most salient to patients and families.

Research Question 10: How do These Frameworks Relate to Quality Improvement Strategies Evaluated in the Previous Closing the Quality Gap Series Reports? The IOM Priorities Report highlighted care coordination as a topic that cut across other specific clinical areas that were priorities for national action (e.g., hypertension, diabetes, asthma, etc.) that were covered in previous reports from our Closing the Quality Gap series. The quality improvement strategies evaluated in these previous reports—namely patient education, self management, provider education, provider reminders, audit and feedback, relay of clinical data, organizational change, financial and regulatory incentives—are relevant to care coordination. While most do not target coordination of care, these strategies share the objective of improving care through changing patient, provider or organizational behavior, and can be viewed through the Andersen behavior framework, which highlights the importance of “predisposing” or “enabling” factors (e.g., financial incentives or provider education). In addition, many of the strategies relate to two other conceptual frameworks described in the report-the organizational design and relational coordination frameworks (e.g., provider reminders as an operational process that improves information transfer; patient education and self-management aimed at enhancing communication between patient and physician, which in turn might result in more coordinated care). Finally, many of the quality improvement interventions categorized as organizational change strategies are the same as those reviewed here as care coordination interventions (e.g., case management, disease management, creation of multidisciplinary teams). These reports were not included in our review, as they are all part of the Closing the Quality Gap series.