Section 6.1 Optimize

Optimization Strategies for Transitions of Care and Care Coordination

Use this tool to understand how to apply electronic health records (EHR) and health information exchange (HIE) to improve transitions of care and care coordination, which are essential to improving the quality of our care overall.

Time needed: 8 – 12 hoursSuggested other tools: 2.3 Visioning, Goal Setting and Strategic Planning for EHR and HIE

Introduction The National Transitions of Care Coalition (NTOCC) has observed: “In spite of world-class clinical advancements and talent, the United States’ health and long term care system is plagued by suboptimal care quality. Problems of underuse, overuse, and misuse of health care all contribute to these quality issues. Care episodes often involve numerous settings and multiple highly-specialized professionals, with little or no communication between them.”1

A study conducted for the National Partnership for Women & Families (www.nationalpartnership.org/site/DocServer/Lake_Poll_Media_Report_Final.pdf?docID=6242) found that 74 percent of those surveyed said that they wished their doctors talked and shared information with each other. Forty-five percent said that they have had to act as communicators between doctors who were not talking to each other.

How to Use 1. Distinguish between transitions of care and care coordination.

2. Plan approaches to how your LPH department may be able to improve transitions of care and care coordination.

3. Utilize EHRs, HIE, and other health information technology (HIT) to support transitions of care and care coordination.

4. Communicate LPH department capabilities to those among whom care is coordinated to ensure their use of EHR and HIE.

Transitions of Care and Care CoordinationThe NTOCC distinguishes between transitions of care and care coordination (http://www.ntocc.org/WhoWeServe/HealthCareProfessionals.aspx):

Transitions of care “refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change…Transitions of care are a set of actions designed to ensure coordination and continuity of care. They should be based on a comprehensive care plan and the availability of practitioners who have current information about the patient’s treatment goals, preferences, and health or clinical status.”

1 National Transitions of Care Coalition, 2010. Position Paper: Improving Transitions of Care with Health Information Technology, available at: http://www.ntocc.org/Portals/0/PDF/Resources/HITPaper.pdf

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Care coordination is a broader concept, sometimes with a more nebulous definition. NTOCC describes care coordination as “the deliberate organization of patient care activities among two or more participants (including the patient and/or the family) to facilitate the appropriate delivery of healthcare services.” The Agency for Healthcare Research and Quality (AHRQ)2 has identified five key elements comprising care coordination:

o Numerous participants are typically involved.

o Coordination is necessary when participants depend on each other to carry out disparate activities in a patient’s care.

o 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.

o In order to manage required patient care activities, participants rely on exchange of information.

o The goal of care activities integration is facility-appropriate delivery of health care services.

The AHRQ study also cites some key attributes of care coordination that you can use as a checklist or springboard for discussion to break down traditions and improve results:

o Collaboration

Interactions based on shared power and authority and mutual respect for the unique abilities of each participant.

Cooperative problem-solving and decision making, where participants achieve better patient care by working together than would have been possible individually.

o Teamwork

Individuals from different disciplines contribute specialized knowledge.

Nonhierarchical relationships.

Participants act according to situational demands rather than traditional organizational roles.

Mutual adjustments are made among participants to coordinate care, especially as the level of interdependence among participants’ separate activities increases.

o Continuity of care—the extent to which the appropriate care is provided at the right time and in the right order by the right persons

Informational continuity is use of information about past events and personal circumstances to make current care appropriate for each individual.

Interpersonal continuity is the ongoing therapeutic relationship between a patient and one or more clinicians.

Management continuity is a consistent and coherent approach to managing a health condition that responds to the patient’s changing needs.

2 McDonald, KM et al. 2007 Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7 Care Coordination) Agency for Healthcare Research and Quality. Available at: http://www.ncbi.nlm.nih.gov/books/NBK44012/

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Approaches to Improving Transitions of Care and Care CoordinationThe following table lists key considerations proposed by the NTOCC and others for contributing to successful transitions of care and care coordination. Also listed are the types of EHR functions, HIE services, and other HIT that may be needed. Determine the steps your LPH department may be able to impact and the type of technology you would seek to acquire.

Considerations for Improving Transitions of Care and Care Coordination (Adapted from NTOCC)

Technology Suitable for Supporting Transitions of Care and Care Coordination

Improve communications during transitions between providers, patients, and family caregivers and as LPH coordinates care among different providers for one episode of care.

Clinical summaries in CCD or C-CDA format HIO to support querying for additional needed information Personal health record ADT

Ensure medication reconciliation at every transition of care.

Medication list management from HIO Medication reconciliation software in EHR

Expand the role of pharmacists in transitions of care in respect to medication reconciliation.

Tele-pharmacy consults Drug knowledge database accessible to all stakeholders Use of fill status notification in e-prescribing systems also available as part of medication list management from HIO

Establish points of accountability for sending and receiving care, especially for physician oversight.

LPH use of provider portal; portal to LPH for providers to use Workflow support in EHR HIO support for tracking patient episodes of care

Increase the use of case management and professional care coordination.

Directory of community services maintained by an HIO Directory of providers, care coordinator/case manager specific to each client maintained by an HIO

Implement payment systems that align incentives.

Although this requires national health reform, on a local level an HIO could be a convener for accountability in care Integrate clinical and financial information and use analytics tools at the local and community levels to promote the health care value proposition

Develop performance measures to encourage better transitions of care.

Embedded evidence-based knowledge in EHR

Adopt standardized ways to exchange information to avoid adverse consequences for patient care.

Ensure EHR and HIE follow technical, semantic, and process interoperability standards

Utilize clinical decision support to alert user that additional information is needed

Inclusion of clinical decision support rules that looks for necessary information and alerts user to query HIO

Utilize clinical decision support to alert caregivers of signs or symptoms that could worsen and require re-hospitalization or emergency department visit.

Inclusion of clinical decision support rules in EHR

Communications About HIE Capabilities

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In order to meet LPH department goals for care coordination, it is essential that those with whom care must be coordinated participate in HIE and have EHR systems that support generation of standardized clinical summaries, problem lists, medication lists, etc.

Ongoing communications with HIE organization (HIO) participants is essential to alert everyone concerning your new capabilities and for you to keep current with new providers coming on board (see Section 5.2 Ongoing Exchange Partner Communications). It may be necessary to be proactive and not simply wait for an HIO to update its directory or to apply a “hit-or-miss” approach to HIE when a need arises. Reach out directly to providers with whom you regularly coordinate care. Encourage them to adopt the Direct protocol for email, at a minimum.

Copyright © 2014 Stratis Health. Updated 03-18-14

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