1. Coordinating Care Sierra Dulaney Lisa Fassett Morgan Little McKenzie McManus Summer Powell Jackie Richardson

2. Objectives Understand the definition and characteristics of care coordination. Understand the definition and characteristics of care coordination. Identify individuals involved in coordinating care. Identify individuals involved in coordinating care. Identify positive outcomes and barriers to ineffective care coordination. Identify positive outcomes and barriers to ineffective care coordination. Understand the importance of care coordination on patient care. Understand the importance of care coordination on patient care.

3. Care Coordination Deliberate integration of patient care activities between two or more participants involved in a patients care to facilitate the appropriate delivery of healthcare services Deliberate integration of patient care activities between two or more participants involved in a patients care to facilitate the appropriate delivery of healthcare services

4. Goals of Coordinating Care Improve care and achieve quality by facilitating and carefully considering feedback from all patients regarding coordination of their care Improve care and achieve quality by facilitating and carefully considering feedback from all patients regarding coordination of their care Improve communication around medication information Improve communication around medication information Work to reduce 30 day re-admission rates Work to reduce 30 day re-admission rates Work to reduce preventable emergency department (ED) visits by 50% Work to reduce preventable emergency department (ED) visits by 50%

5. Characteristics What is involved in care coordination? What is involved in care coordination? Teamwork Teamwork Communication Communication Delegation Delegation Leadership Leadership Competency Competency Collaboration Collaboration Patient-Centered Care Patient-Centered Care

6. Examples of Care Coordinators Nurses Nurses Nurse Care Coordinators Nurse Care Coordinators Nurse Practitioners/Physicians Nurse Practitioners/Physicians Insurance Companies Insurance Companies Case Managers Case Managers

7. Nurses The essence of nursing is coordinating care of the patient The essence of nursing is coordinating care of the patient Provides direct patient care Provides direct patient care Ensure safety Ensure safety Client advocate Client advocate Educate patients and family members Educate patients and family members Communicates patient status to other health care providers Communicates patient status to other health care providers

8. Nursing Care Coordinator Assign nurses, therapists, and personal care and nursing sides to work with certain patients for specific times Assign nurses, therapists, and personal care and nursing sides to work with certain patients for specific times Make schedules for administering therapies or treatments to patients Make schedules for administering therapies or treatments to patients Read notes and charts left by the individuals who work with the patients, noting any problem when care is delivered and handling these problems when they arise Read notes and charts left by the individuals who work with the patients, noting any problem when care is delivered and handling these problems when they arise

9. Physicians and Nurse Practitioners Continual involvement of the family Continual involvement of the family Timely legible communication between patient and outpatient physicians Timely legible communication between patient and outpatient physicians Meticulous handoffs at every transition Meticulous handoffs at every transition Clear delineation of their responsibilities at their hospital stay and when the patient returns home Clear delineation of their responsibilities at their hospital stay and when the patient returns home

10. Case Managers Coordinate the integration of social services/case management functions into the patient care, discharge, and home planning processes with other hospital departments, external service organizations, agencies and healthcare facilities. Coordinate the integration of social services/case management functions into the patient care, discharge, and home planning processes with other hospital departments, external service organizations, agencies and healthcare facilities. Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery. Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery. Promote effective and efficient utilization of clinical resources. Promote effective and efficient utilization of clinical resources.

12. Standards for Care Coordination Preferred Practices: Healthcare “Home” Domain Preferred Practices: Healthcare “Home” Domain Preferred Practice 1: The patient shall be provided the opportunity to select the healthcare home that provides the best and most appropriate opportunities to the patient to develop and maintain a relationship with healthcare providers. Preferred Practice 1: The patient shall be provided the opportunity to select the healthcare home that provides the best and most appropriate opportunities to the patient to develop and maintain a relationship with healthcare providers. Preferred Practice 2: The healthcare home or sponsoring organizations shall be the central point for incorporating strategies for continuity of care. Preferred Practice 2: The healthcare home or sponsoring organizations shall be the central point for incorporating strategies for continuity of care. Preferred Practice 3: The healthcare home shall develop infrastructure for managing plans of care that incorporate systems for registering, tracking, measuring, reporting, and improving essential coordinated services. Preferred Practice 3: The healthcare home shall develop infrastructure for managing plans of care that incorporate systems for registering, tracking, measuring, reporting, and improving essential coordinated services. Preferred Practice 4: The healthcare home should have policies, procedures, and accountabilities to support effective collaborations between primary care and specialist providers, including evidence-based referrals and consultations that clearly define the roles and responsibilities. Preferred Practice 4: The healthcare home should have policies, procedures, and accountabilities to support effective collaborations between primary care and specialist providers, including evidence-based referrals and consultations that clearly define the roles and responsibilities. Preferred Practices 5: The healthcare home will provide or arrange to provide care coordination services for patients at high risk for adverse health outcomes, high service use, and high costs. Preferred Practices 5: The healthcare home will provide or arrange to provide care coordination services for patients at high risk for adverse health outcomes, high service use, and high costs.

13. Standards for Care Coordination Preferred Practices: Proactive Plan of Care and Follow-up Domain Preferred Practices: Proactive Plan of Care and Follow-up Domain Preferred Practice 6: Healthcare providers and entities should have structured and effective systems, policies, procedures, and practices to create, document, execute, and update a plan of care with every patient. Preferred Practice 6: Healthcare providers and entities should have structured and effective systems, policies, procedures, and practices to create, document, execute, and update a plan of care with every patient. Preferred Practice 7: A systematic process of follow-up tests, treatments, or services should be established and be informed by the plan of care. Preferred Practice 7: A systematic process of follow-up tests, treatments, or services should be established and be informed by the plan of care. Preferred Practice 8: The joint plan of care should be developed and include patient education and support for self-management and resources. Preferred Practice 8: The joint plan of care should be developed and include patient education and support for self-management and resources. Preferred Practice 9: The plan of care should include community and nonclinical services as well as healthcare services that respond to a patient’s needs and preferences and contributes to achieving the patient’s goals. Preferred Practice 9: The plan of care should include community and nonclinical services as well as healthcare services that respond to a patient’s needs and preferences and contributes to achieving the patient’s goals. Preferred Practice 10: Healthcare organizations should utilize cardiac rehabilitation services to assist the healthcare home in coordinating rehabilitation and preventive care for patients with a recent cardiovascular event. Preferred Practice 10: Healthcare organizations should utilize cardiac rehabilitation services to assist the healthcare home in coordinating rehabilitation and preventive care for patients with a recent cardiovascular event.

14. Standards for Care Coordination Preferred Practices: Communication Domain Preferred Practices: Communication Domain Preferred Practice 11: The patient’s plan of care should always be made available to the healthcare home team, the patient, and the patient’s designees. Preferred Practice 11: The patient’s plan of care should always be made available to the healthcare home team, the patient, and the patient’s designees. Preferred Practice 12: All healthcare home team members, including the patient and his or her designees, should work within the same plan of care and share responsibility for their contributions to the plan of care and for achieving the patient’s goals. Preferred Practice 12: All healthcare home team members, including the patient and his or her designees, should work within the same plan of care and share responsibility for their contributions to the plan of care and for achieving the patient’s goals. Preferred Practice 13: A program should be used that incorporates a care partner to support family and friends when caring for a hospitalized patient. Preferred Practice 13: A program should be used that incorporates a care partner to support family and friends when caring for a hospitalized patient. Preferred Practice 14: The provider’s perspective of care coordination activities should be assessed and documented. Preferred Practice 14: The provider’s perspective of care coordination activities should be assessed and documented.

15. Standards for Care Coordination Preferred Practices: Information Systems Domain Preferred Practices: Information Systems Domain Preferred Practice 15: Standardized, integrated, interoperable, electronic, information systems with functionalities that are essential to care coordination, decision support, and quality measurement and practice improvement should be used. Preferred Practice 15: Standardized, integrated, interoperable, electronic, information systems with functionalities that are essential to care coordination, decision support, and quality measurement and practice improvement should be used. Preferred Practice 16: An electronic record system should allow the patient’s health information to be accessible to caregivers at all points of care. Preferred Practice 16: An electronic record system should allow the patient’s health information to be accessible to caregivers at all points of care. Preferred Practice 17: Regional health information systems, which may be governed by various partnerships, including public/private, state/local agencies, should enable healthcare home teams to access all patient information. Preferred Practice 17: Regional health information systems, which may be governed by various partnerships, including public/private, state/local agencies, should enable healthcare home teams to access all patient information.

16. Coordinating care within the Hospital Labs Labs Radiology Radiology Pharmacy Pharmacy Respiratory Therapy Respiratory Therapy Doctor’s orders Doctor’s orders Chaplin services Chaplin services Dietician Dietician Physical, Occupational, and Speech Therapy Physical, Occupational, and Speech Therapy Social Worker Social Worker

17. Coordinating care outside the hospital Insurance Insurance Home health Home health Specialists Specialists Primary care physicians Primary care physicians

18. Barriers Lack of time Lack of time Lack of communication Lack of communication High patient to health care provider ratio High patient to health care provider ratio Confusion with mixed paper and electronic charting Confusion with mixed paper and electronic charting Clashing personality Clashing personality Role confusion Role confusion

19. Positive Coordination Outcomes Increased quality of care for patients Increased quality of care for patients Fewer mistakes Fewer mistakes Fewer readmissions Fewer readmissions Reduced costs Reduced costs Patient satisfaction Patient satisfaction Staff satisfaction Staff satisfaction

20. Poor Coordination Outcomes Medication errors Medication errors Hospital readmissions Hospital readmissions Avoidable emergency departments visits Avoidable emergency departments visits Increased cost to the hospital and patient Increased cost to the hospital and patient

21. References National Quality Forum. Washington, DC, (2010). Preferred practices and performance measures for measuring and reporting care coordination: A consensus report. ISBN: 978-1- 933875-47-7. Retrieved from website: http://www.qualityforum.org/Publications/2010/10Preferred_Practices_and_Performance_M easures_for_Measuring_and_Reporting_Care_Coordination.aspx National Quality Forum. Washington, DC, (2010). Preferred practices and performance measures for measuring and reporting care coordination: A consensus report. ISBN: 978-1- 933875-47-7. Retrieved from website: http://www.qualityforum.org/Publications/2010/10Preferred_Practices_and_Performance_M easures_for_Measuring_and_Reporting_Care_Coordination.aspx Johnson, D., & Burik, D. (2010). 5 strategies for coordinating postacute care. Hfm (Healthcare Financial Management), 64(7), 70-74. Johnson, D., & Burik, D. (2010). 5 strategies for coordinating postacute care. Hfm (Healthcare Financial Management), 64(7), 70-74. Mitka, M. (2011). Project aims for better patient health through coordinating primary care. JAMA: Journal Of The American Medical Association, 306(20), 2205 Mitka, M. (2011). Project aims for better patient health through coordinating primary care. JAMA: Journal Of The American Medical Association, 306(20), 2205