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In Focus: Toward a System of Coordinated Care

By Martha Hostetter

Conversations about the complex and fragmented U.S. health care system often reference an elderly female patient. Perhaps she is relatively healthy, only requiring a few prescriptions to manage her chronic conditions. Then she has a setback—a fall or a stroke—and winds up in the hospital, where several new doctors treat her and prescribe medications. What happens when she is discharged has important implications for her recovery. But there are few safeguards in place to ensure she will be able to keep track of her care regimen or reach appropriate medical personnel if she needs help.

Providers "take care of people, send them out into the world, and are not sure they are going to be okay," says Jane Brock, M.D., of the Colorado Foundation for Medical Care, the state's quality improvement organization.

Many patients, not just frail elders, suffer from a lack of oversight and continuity in their care, particularly during transitions from one provider to another or from hospitals to rehabilitation centers, nursing facilities, or homes.

A study led by Eric Coleman, M.D., of the University of Colorado followed Medicare patients for 30 days after hospital discharge and found about a quarter of patients did not progress smoothly on the road to recovery. Instead, they moved from high-intensity to lower-intensity interventions then back to high-intensity interventions. Given that researchers identified 45 unique patterns of care, it's not surprising that there is considerable confusion and error along these pathways.

For example, a 2005 Commonwealth Fund survey of patients with health problems in six countries, including the U.S., found that at least a third of hospital patients did not receive instructions about what symptoms to watch for when discharged, did not know who to contact with questions, or were left without arrangements for follow-up care. Additional research led by Alan J. Forster, M.D., of the University of Ottawa has found that, within three weeks of leaving the hospital, nearly one of five patients experiences an adverse event and that many of these events (12%) could have been ameliorated or prevented through simple steps.

Clearly, procedures to manage transitions and ensure communication among health care professionals and with patients are needed. Such tools could help patients and their providers to work together to improve health outcomes and prevent medical or medication errors. In addition, better coordination of care could reduce costs by eliminating delays, duplicate tests and other redundancies, and preventable complications.

Measures Identify Areas to Improve
Because patients and their families are often the only constants in an episode of care, researchers rely on their feedback to gauge these problems. Patient surveys have brought to light communication failures, ineffective hand-offs, and documentation deficiencies.

Coleman and colleagues created a 15-item Care Transitions Measure to further clarify deficiencies in this area. It asks patients whether they understand their responsibilities and medications upon leaving the hospital, and whether their preferences were taken into account. The tool, which has demonstrated the ability to discriminate between patients discharged from the hospital who did and did not experience a subsequent emergency visit or re-hospitalization, has been adopted by health plans and other purchasers. In addition, the National Quality Forum has endorsed a three-item version of the tool for use in public reporting.

Massachusetts Health Quality Partners (MHQP), a coalition that provides performance information to physicians, also uses patient surveys to help physician practices gauge how well they are coordinating care. Barbra Rabson, MHQP's executive director, says the goal is to provide actionable information on ways to improve. For example, in the summer of 2005, nearly 25 percent of adult patients across the state reported they did not always receive test results from their doctor's office. "Providers might see this finding and say, 'Okay, we need to focus on communicating test results,'" Rabson says. "'Are the test results coming back to us? If so, are they on a piece of paper that might get lost? What kinds of safeguards can we put in place to make sure this problem doesn't occur?'"

Once care transition measures are established, they have the potential to encourage better performance. The Integrated Healthcare Association, a California-based group of health plans, physician groups, and hospitals, uses patient care experience reports to help calculate pay-for-performance (P4P) incentives for physician groups throughout the state. However, since the P4P program's implementation in 2002, there has been little evidence of overall improvement in patient experiences of care, with shortfalls notable in the area of care coordination.

Tammy Fisher of the Pacific Business Group on Health (PBGH), a coalition of health care purchasers, hopes to change this trend. Because "there is not a lot of information about how to improve care coordination," particularly in ambulatory care settings, she is leading a Commonwealth Fund–supported learning collaborative among 13 California practices to test possible strategies. These include: always notifying patients of test results, regardless of outcome; always printing medication lists during office visits; and always reviewing medical charts before going into the examining room. So far, these approaches have resulted in improvement on patient-reported measures of care coordination.

Supporting Patients and Families
In the absence of a coordinated care system, patients' family members often must learn to juggle medication regimens, monitor symptoms, and deliver ongoing care. And because hospital stays are much shorter than in previous decades, these caregivers may have to cope with complex treatment routines.

"Families are being asked to do for their loved ones what a team of health care workers used to do in the hospital," says Suzanne Mintz, president and co-founder of the National Family Caregivers Association (NFCA). NFCA, a support and advocacy group, runs workshops to teach caregivers how to communicate effectively with health care professionals and to get the information they need. The NFCA also encourages caregivers to track all medications on a single form and bring it with them to all medical encounters. (Such a list could aid providers in performing medication reconciliation, a process recommended by the Institute for Healthcare Improvement and others in which a list of all of a patient's medications—including the drug name, dosage, frequency, and route of administration—is compared against admission, transfer, and/or discharge orders to ensure safety between all care transitions.)

But patients and their caregivers shouldn't be expected to close all of the gaps in the health system. "In an ideal world, caregiving families would have a care coordinator who knows their history," Mintz says. "Then, during times of crisis or transition, they would be there to help them through."

Coleman's Care Transitions Program offers one such model of support. Patients work with "transition coaches" for 30 days after discharge, using a series of role-playing exercises, medication reviews, and a personal health record to build their self-management skills. The coaches also help patients obtain timely follow-up care and watch for "red flag" symptoms. A growing body of research shows patients who receive this treatment are significantly less likely to be readmitted to the hospital, and more likely to achieve their goals for symptom management and recovery.

In another proven model, researchers at the University of Pennsylvania formed a partnership with Aetna to promote care coordination among patients at high risk for poor transitions and repeat hospitalizations—elderly adults with multiple chronic conditions. Advanced practice nurses (APNs) work with family caregivers and physicians to help frail elders make the transition from hospital to home.

"The nurses work with patients, their families, and other health team members to design a discharge plan and then follow them for an average of two months to implement it," says Mary Naylor, R.N., Ph.D., of the University of Pennsylvania School of Nursing, who is leading the project. "The focus isn't just on one specific issue such as the patient's heart failure or diabetes. Rather, it is a holistic plan of care, driven by priority issues that are identified by both the patient and APN."

Two hundred Aetna members are now receiving this service in the mid-Atlantic region, and it is now being tested in a Medicare Health Support project in Chicago. Enrollment is also under way at three Kaiser Permanente sites. If the projects demonstrate positive quality and cost outcomes, Aetna and Kaiser Permanente will consider widespread diffusion in their organizations—translating a promising model into clinical practice.

Finally, patients with congestive heart failure present particular challenges for care coordination, because they often take multiple medications and have complex diet and activity regimens. As part of a quality improvement initiative led by Catholic Healthcare Partners, Heart Failure Guidelines Applied in Practice, six hospitals each trained one nurse to act as a "heart failure advocate." After receiving training in evidence-based care, these advocates work with patients on an ongoing basis, rather than just after hospital discharge.

"The advocates became skilled at figuring things out in the moment—not all questions involving chronic care have black or white answers," says Don Casey, M.D., principal investigator for the project. "Sometimes it's as simple as making sure patients came back on time to see the doctor; sometimes it means making sure they are getting key therapies and know how to manage their condition." An analysis of the intervention showed that patients under the care of the advocates experienced fewer readmissions and a longer time between readmissions than patients not receiving such assistance.

System-Wide Reforms Needed
In addition to patient coaching and guidance, care coordination requires effective handoffs among primary care and specialist physicians, nurses, therapists, social workers, and other professionals. But there are often not clear lines of accountability in the intervals between discharge from one setting and admission to another.

Further, there are few mechanisms to ensure that instructions are clearly relayed from place to place and person to person. Illegible handwriting, administrative complexity, and concern over patient privacy rules all contribute to the problem. While technology such as electronic medical records could help to smooth the transfer of medical information, most systems aren't interoperable across institutions. Further, regional health information portals are needed to enable providers to access all patient information through a single point of access.

Finally, care coordination isn't likely to improve unless there are mechanisms in place to pay for it. The current fee-for-service model offers few incentives for providers to ensure smooth transitions, provide anticipatory guidance, or follow-up with patients.

As a result, "providers often miss opportunities for collaboration since the payment system rewards neither team management nor the integration of services across care settings," concludes a recent Institute of Medicine report, Rewarding Provider Performance: Aligning Incentives in Medicare. It recommends implementing measures for public reporting and payment incentives that provide "comprehensive and longitudinal assessments of provider and system improvement."

Improving care coordination will require broader system reforms that address may of the shortcomings of the health system, including the lack of timely, accessible, and patient-centered care. Efforts are needed to improve preventive and chronic care, as well as end-of-life care.

"People want to know how you pay for care coordination," says Judith Miller Jones of the National Health Policy Forum. "I start with the idea that doctors and other health care providers are first and foremost professionals: how do you reward them for practicing to the best of their capabilities?"

But providers can't solve the problem single-handedly, says Jones. They "can't remember everything about every patient, every type of drug interaction . . . We need electronic medical records, decision support, and health care teams, and we need to get patients involved. Most people appreciate that there's a problem; it's just hard to fix."

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