I attached the file with the questions and documents to be used to answer the questions.
QUESTIONS AND INSTRUCTIONS
THE CHALLENGE OF COORDINATING HEALTH CARE SERVICES/ CASE STUDY 1:
DUE DATE – 11:59 PM, THURSDAY OCTOBER 31, 2019.
PURPOSE OF CASE STUDY:
To understand the general concept of Coordination in organizations, and the main types of Coordination practiced in different types of organizations.
To understand the specific meanings of Coordination in the delivery of health care services.
To understand some of the key Coordination problems in health care service delivery, focusing on
Problems faced by Physicians.
Problems faced by Hospitals.
To know some Coordination solutions currently being implemented by health care service organizations.
READ THE INDICATED READINGS, WHICH ARE ATTACHED.
PROVIDE WRITTEN RESPONSES TO THE QUESTIONS POSED in 3. BELOW.
Your response via BlackBoard Assignments should have the following format and follow the rules indicated below:
Double spaced.
In Arial 12 font.
No more than 2 pages long.
Your response should be in a separate Microsoft Document attached to and submitted through Blackboard Assignment: Case Study 1.
Each paragraph of the response should correspond to one of the Questions below – A., B., etc.
In your responses, without using too many sentences, use the attached documents to give your specific answer to each question.
If you have made and posted more than one response on Blackboard, I will read, grade, and respond to your most recent response by day and date.
QUESTIONS – PROVIDE A WRITTEN RESPONSE:
Coordination Issues in Organizations: READING 1.
Briefly describe the nature and purpose of Coordination in organizations – in no more than 2-3 sentences.
How does Mutual Adjustment work as a type of Coordination, and in which kinds of organizations is it used?
Coordination in Health Care Service Delivery – READING 2 and READING 3, ESPECIALLY SLIDES 2 AND 3.
Briefly define the nature and purpose of Coordination of Clinical Services in Health Care Service Delivery.
Especially in Medicare, but also in the general population of health insurance enrollees, what kinds of patients are especially in need of intensive and ongoing efforts at continuous Coordination of care?
Problems for Physicians in the Coordination of Health Care Service Delivery – READING 2 and READING 3, ESPECIALLY SLIDE 4. Also READING 4.
Briefly NAME AND DESCRIBE one (1) Coordination problem commonly faced by Physicians.
Problems for Hospitals in the Coordination of Health Care Service Delivery – READING 2 and READING 3, ESPECIALLY SLIDES 5 THROUGH 7. Also READING 5.
Briefly NAME AND DESCRIBE two (2) Coordination problems related to Communication commonly faced within Hospitals.
Problems with Care Transitions – READING, especially PAGES 2 AND 3.
Briefly name and describe two (2) Care Transition Coordination problems.
Briefly name and describe two (2) solutions to Care Transition problems
READING 5: Health Care’s ‘Dirty Little Secret’: No One May Be Coordinating Care
By Roni Caryn Rabin APRIL 30, 2013
kaiser health news april 30, 2013
Betsy Gabay saw a rotating cast of at least 14 doctors when she was hospitalized at New York Hospital Queens for almost four weeks last year for a flare-up of ulcerative colitis. But the person she credits with saving her life is a spry, persistent 75-year-old with a vested interest — her mother.
Illustration by Arthur Giron
Alarmed by her daughter’s rapid deterioration and then by her abrupt discharge from the hospital, Gabay’s mother contacted a physician friend who got her daughter admitted to Mount Sinai Medical Center in Manhattan.
By then, Gabay, 50, had a blood clot in her lung and a serious bacterial infection, C. difficile. She also needed to have her diseased colon removed, according to the doctors at Mount Sinai. Had the problems been left unaddressed, any one of them might have killed her.
Coordinated care is touted as the key to better and more cost-effective care, and is being encouraged with financial rewards and penalties under the 2010 federal health care overhaul, as well as by private insurers. But experts say the communication failures that landed Gabay in a rehab center, rather than in surgery, remain disturbingly common.
“Nobody is responsible for coordinating care,” said Dr. Lucian Leape, a Harvard health policy analyst and a nationally recognized patient safety leader. “That’s the dirty little secret about health care.”
Advocates for hospital patients and their families say confusion about who is managing a patient’s care — and lack of coordination among those caregivers — are endemic, contributing to the estimated 44,000 to 98,000 deaths from medical errors each year.
A landmark report by the Institute of Medicine in 1999 cited the fragmented health-care system and patients’ reliance on multiple providers as a leading cause of medical mistakes. Leape, who helped author that report, says there have been improvements since, but “we have not done enough.”
Subsequent studies suggest the toll may be even higher than the Institute of Medicine estimated. A 2010 federal report projected that 15,000 Medicare patients every month suffered such serious harm in the hospital that it contributed to their deaths.
Gabay experienced such shortcomings firsthand. During her 26 days in the Queens hospital, she said doctors would do rounds and “I couldn’t tell one name from the next. I didn’t know whether it was the gastroenterologist, or the nutritionist, or the physical therapist.”
When she was discharged to a rehab center, she was suffering from acute abdominal pain and bloody diarrhea, and was too weak to get out of bed.
Illustration by Arthur Giron
“I thought I was being sent there to die,” said Gabay, who made a complete recovery once she was treated at Mount Sinai for the infection and blood clot and her colon was removed. Officials at New York Hospital Queens declined numerous requests for comment, citing patient confidentiality.
A New Set Of Doctors
Patients such as Gabay are often surprised to discover that the primary-care physician with whom they have an ongoing relationship isn’t the doctor overseeing their hospital care and is unlikely to be informed about their progress.
Instead, hospitals have staff doctors called hospitalists who are supposed to manage a patient’s care, coordinating the various specialists, managing medications and then overseeing the transition back home.
“I see my job as an orchestra conductor pulling it all together,” said Robert M. Wachter, chief of hospital service at UCSF Medical Center in San Francisco, who coined the term “hospitalist” in 1996. “I may only spend a few minutes in the [patient’s] room, but the other subspecialists are communicating to me, and I’ll integrate it so we give the patient one uniform message.”
But that system is vulnerable to breakdowns. Patients and family members meet hospitalists, along with many other medical specialists, when they’re in crisis. Even when hospitalists explain their role, patients may be too overwhelmed – or ill, medicated, or disoriented — to absorb the information. As a result, they often don’t distinguish the hospitalist from the dozens of other caregivers they see.
“Unless the patient has written it down, they will say, ‘Someone was here, but I don’t remember what they said,'” said Ilene Corina, founder of PULSE, a nonprofit organization in New York that works to improve patient safety.
For families, the sense that no one is on top of their loved one’s care can be one of the most harrowing experiences related to a hospital admission.
Miscommunications are also more likely to occur under the strain of heavy workloads and the routine transfer of responsibility from one hospitalist to another during a patient’s stay. Hospitalists routinely work seven to 15 days in a row on shifts that each last 10 to 12 hours to provide patient continuity.
But many doctors report juggling too many patients to do their jobs well. Nearly four in 10 hospitalists responding to a survey from Johns Hopkins University School of Medicine said they struggle with unsafe workloads at least once a week. Almost a quarter believed their workload “likely contributed” to patient complications and even deaths. Most of them defined a safe workload as up to 15 patients per shift.
Workload issues are “the elephant in the room that cannot be ignored,” said Henry Michtalik, lead author of the journal article about the survey. “We have to find that balance between safety, quality and efficiency.”
Communication Snafus
Retired Washington D.C. internist Marsha Wallace had heard plenty of horror stories about hospital patients falling through the cracks. Still, she was troubled last fall during her own stay at a local hospital when she overheard doctors delivering entirely conflicting messages to the elderly cancer patient who was her roommate.
“First the surgeon came in and told her he hadn’t found anything,” Wallace recalled. “Then the gastroenterologist came in and said, ‘I just did a CT scan; you have an obstructed kidney.’ Then the internist came in and said, ‘We don’t know what’s wrong, so we may send you to [Johns] Hopkins.’ Then the social worker came in and said, ‘We’re going to discharge you to a rehab hospital.'”
The caregivers didn’t appear to be talking to one another, Wallace said.
Sharon Flank, chief executive of an anti-counterfeiting company in Silver Spring, Md., saw her mother suffer from one complication after another following lung surgery: a bad reaction to a painkiller, a hernia that required surgery, a serious cardiac problem and a blood clot.
When Flank’s mother went back to the lung surgeon for a postoperative appointment, “she was in miserable shape because all these other horrible things had happened,” Flank said. “But her incision looked good, and the surgeon looks at her and says, ‘I did a beautiful job.’ ”
Patients are most vulnerable to coordination problems when their recovery doesn’t go as planned or a medical mistake has occurred, say advocates, patients and others. That’s when complications — and potential liabilities – develop.
Karen Curtiss, a Lake Forest, Ill., writer, witnessed what she said were so many mistakes in her father’s hospital care that she founded an advocacy group, Campaign Zero, in response.
Shortly after Curtiss’s father had a lung transplant in 2005, he fell as he tried to make it from the bathroom to his bed without waiting for a nurse. Hospital staff put him in horizontal traction until a neurologist could examine him, even though that position can cause fluid to pool in the lungs. The fall occurred on a Friday, and the neurologist didn’t come until Sunday evening; by then, Curtiss’s father had developed pneumonia, which compromised the newly transplanted lung. Other complications followed, including a blood clot to his lung and a staph infection. He died soon afterward.
“His death certificate said he died of complications of pulmonary fibrosis,” said Curtiss, who has written a handbook for families with loved ones in the hospital. “I think it should have listed every single thing: the complications, the blood clot, a fall, infections, pneumonia.”
Fixing the System
Although hospitals, the federal government, nonprofit groups and insurers want to improve the system, efforts to boost coordination and teamwork still have a long way to go.
Last summer, the Joint Commission, the nation’s hospital accrediting group, developed a tool for hospitals to help guide communication when a patient is transferred from one hospital setting to another – for instance, from an intensive care unit to a regular floor.
Some medical centers have taken steps to improve communication, assigning color-coded ID tags or scrubs to staff members so patients know who’s a nurse and who’s a doctor, and installing white boards in patient rooms, where a nurse starting a shift can jot down his or her name. At some facilities, hospitalists write their names on those boards, and hand patients and their relatives business cards or sticky notes with their photos.
A few hospitals have gone further. At the Mayo Clinic in Rochester, Minn., patients having surgery attend a pre-admission education class so they know “almost to the hour, let alone to the day, what’s going to happen,” said Chief Medical Officer Michael Rock.
In Pennsylvania, Geisinger Health System has developed a checklist on laminated cards that fit in caregivers’ pockets. It includes questions that doctors and nurses need to keep uppermost when reviewing cases, such as: “Is the patient taking high-risk medications? When is the patient going home? Does the patient have any catheters or lines that should come out?”
Virginia Mason Health System in Seattle completely overhauled how they did things after sending representatives to Japan to learn from Toyota. Now nurses spend 90 percent of their time near the patient “so the shift handoffs don’t happen at the nurses’ station anymore,” said Dr. Gary Kaplan, Virginia Mason’s chairman and CEO. “Patients don’t have to use the call button.”
Consumer advocacy organizations, meanwhile, advise patients entering the hospital to have a relative or close friend, or even a hired hand, who can communicate on their behalf and be at their side through the hospitalization. [See sidebar.]
But not all patients have such advocates, and even when they do, playing that role can place a difficult burden on families or make second-class citizens of those who do not, said Wachter, the hospitalist.
When his own mother had lung surgery in Miami several months ago, “I went down there and didn’t leave her bedside,” he said.
2 - Tip Sheet On Staying Safe In The Hospital
By Roni Caryn Rabin APRIL 30, 2013
kaiser health news april 30, 2013
Wanted: an advocate for a hospital patient. Long hours, no pay. Must be articulate, assertive, able to ask tough questions and stay cool under pressure. Blood relative or close friend preferred. Knowledge about the health-care system a plus.
It has become an unwritten rule of hospital care that patients should always have a friend or family member by their bedside to make sure they’re getting the right care and to be on the lookout for medical errors. But while there are some professional advocates out there and some organizations that offer training for family members, most people learn on the job, so to speak.
“It would be ideal to have Dr. Marcus Welby looking in on you and coordinating everything, and giving you a big reassuring smile but that’s not the reality right now,” said Karen Curtiss, who wrote a handbook about managing the care of a hospitalized relative, based on her own experiences (“Safe & Sound in the Hospital” available through PartnerHealth.com).
Curtiss points out that the patient has a right to know the name and position of the physician who is overseeing their hospital care. All care providers should introduce themselves when they come into the room; if they don’t, remind them.
Patients also have a right to review their medical records at the bedside and to receive information about the benefits and risks of any procedure or treatment they are offered. If the patient is mentally competent, he or she can give an advocate permission to see the records; it can be done verbally, and the advocate’s name can be put in the medical chart.
To help advocates, the patient safety organization PULSE has drawn up a checklist that uses the acronym FILMS, which stands for “falls,” “infections,” “literacy,” “medication” and “surgery”:
Falls. Make sure the staff are aware when a patient is at risk of falling, and have the patient evaluated if you are concerned. Falls are a leading cause of hospital injuries.
Infections. Don’t be shy about asking health care providers if they have washed their hands or asking them to do it again in front of you.
Literacy. Read any forms the patient is asked to sign. (He or she may be unable to absorb the information completely.)
Medication. Doctors and hospital staff members should always explain to the patient which drugs they are being given. Ideally, medication should be in the original wrapper. Medication errors injure 1.5 million people each year.
Surgery. Before an operation, make sure the site of surgery is marked and verified by the doctor. The advocate can and probably should be present when this is done. There are still 40 cases every week of surgeries done on the wrong body part. If the patient has not been given antibiotics, ask if there is a reason; taking antibiotics preventively before surgery has been shown to reduce infection risk. Also, make sure the patient has a warm blanket before and after surgery, since staying warm also reduces infection risk.
It’s a good idea to go to the hospital with a notebook and pens, and a file of information including the patient’s insurance, names of doctors, contact information for key family members and friends, and lists of the patient’s allergies, past procedures and surgeries, medications, vitamins, supplements or herbs, and any special dietary needs.
Take antibacterial wipes to wipe down bedrails, the TV remote, phone and doorknobs, says Pulse’s Ilene Corina.
If the advocate feels the patient is in danger and they are not being heard, he or she should approach the nurse’s station and say they are calling a “Condition Help” and need a rapid response team. The phrases “Condition Help” and “rapid response team” are red flags to the hospital staff that the situation is grave, and the words should not be used lightly. “‘Condition Help’ is like calling 911 in the hospital,” Curtiss said. “Ask yourself: ‘If we were not in the hospital, would I call 911?'”
Last but not least, trust your gut: If you think something is wrong, get help.
COORDINATION AND DIVISION OF LABOR
1. COORDINATION OF WORK WITHIN ORGANIZATIONS: GENERAL
Coordination involves a number of functions, including clearing up disputes over who does what (or which team/small group within a department does what); facilitating communication between different work units (departments, teams, small groups) established through the Division of Labor; harmonizing timeframes for accomplishment of tasks and smoothing out differences in work style and definition of "quality work" among different work units; ensuring the work units which depend on each other are on the same page in terms of organizational goals and priorities, and the production of the organization's defined critical outputs.
Special efforts at coordination are needed more and more as an organization is more hierarchical ("vertical") and more reliant on division of labor. This is the case because the more division of labor, and the more layers of management needed to make and communicate decisions to the many individual specialized work units, the more likely there will be miscommunication or overly slow communication of what to do and how to do it.
Also, smaller and very functionally focused units, despite what they offer in terms of quality and efficiency, are likely to lose sight of the overall common organizational goals (including mission and vision), and to focus only on their job, not on their relationship and dependency on the other specialized units needed to get the work of the organization (its outcomes and outputs) produced in a quality and timely manner, and in the right amounts. The danger is that each individual work unit (e.g. department) will focus on its own work only, not on how it works with other units to achieve company goals, outcomes, outputs.
2. COORDINATION OF WORK WITHIN ORGANIZATIONS: DIFFERENT FORMS OF COORDINATION.
Mutual Adjustment – Generally associated with Horizontal/Organic Organizations, and thus with team-based work.
This mechanism is based on the simple process of informal communication. It is used in very small companies, such as a 5-person software shop, or for very, very complicated tasks, such as putting the first person on the moon. Mutual adjustment is the same mechanism used by furniture movers to maneuver through a house, or paddlers to take a canoe downriver, or jazz musicians playing a live engagement. It's especially useful when nobody really knows ahead of time how to do what they're doing.
Direct Supervision – Generally associated with Vertical/Mechanistic Organizations.
Achieves coordination by having one person take responsibility for the work of others, issuing instructions and monitoring their actions. An example is the offensive unit of a football team. Here, there is marked division of labor and specialization, and the efforts of the players are coordinating by a quarterback calling specific plays.
If the organization is large enough, one person cannot handle all the members, so multiple leaders or managers must be used, then the efforts of these people (the managers) are coordinated by a manager of managers, and so on.
Standardization – Generally associated with Vertical/Mechanistic Organizations: EXCEPT – Standardization of Worker Skills may also apply to Horizontal/Organic Organizations in which professionals like doctors and lawyers are the principal workers.
A third mechanism of coordination is standardization. Here, the coordination is achieved "on the drawing board", so to speak, or "at compile-time" if you like, not during the action or "run-time". The coordination is pre-programmed in one of three ways:
Work Processes. An example is the set of assembly instructions that come with a child's toy. Here, the manufacturer standardizes the work process of the parent. Often, the machinery in a factory effectively standardizes work by automatically providing only, say, blue paint when blue paint is needed, and only red paint when red paint is needed.
Outputs. Standardized outputs mean that there are specifications that the product or work output must meet, but aside from that the worker is free to do as they wish. Stereo equipment manufacturers have a lot of freedom in designing their products, but the interface portions of the product (the connections to other stereo devices like CD's, speakers, tape-recorders, etc.) must be the same as everyone else's, or else it would be hard to put together a complete system.
Worker Skills. Professional schools, like medical schools, law school, business school, produce workers that do stuff exactly the same way. How do you treat a staphylococcus infection? You use one of the following antibiotics. It's a series of recipes that are memorized. Employers (e.g., hospitals) can rely on these employees (physicians) to do things the standard way, which allows other employees (e.g., nurses) to coordinate smoothly with them. When a surgeon and an anesthesiologist meet for the first time in the operating room, they have no problem working together because by virtue of their training they know exactly what to expect from each other.
3. SUMMARY: HOW HORIZONTAL AND VERTICAL ORGANIZATIONS ARE DIFFERENT.
A. VERTICAL (MECHANISTIC) ORGANIZATIONS: Large batch production is directly related to the production of relatively standard and uniform goods and services. Although the large size of this kind of organization and the large volume of goods and services produced by the organization necessitate greater specialization in the division and assignment of production tasks (more intensive division of labor), the uniform nature of the goods and services produced FURTHER INCREASE organizational size and extent of division of labor.
Vertical organizations have the size, shape, and basic profile that they do (many levels of management, and extensive division of labor) because of volume of output, type of goods/services, and the predictable environment in which the goods and services are produced.
Vertical Organizations use a “tall” hierarchy of layers of managers to coordinate the specialized work units:
BECAUSE:
Each unit of production (division, department) is only responsible for a very narrowly defined set of activities. No single work unit (department/division) knows a lot about the overall production process for a particular output (good or service);
These UNITS OF PRODUCTION (for example, departments) are very dependent on each other for the completion of critical steps in the overall production process;
BUT because of this narrow focus each department has a much harder time staying focused on achieving the overall goals of the organization, on seeing how their work fits in with the work of the other departments in the organization, and on collaborating and communicating with other departments/divisions to achieve the key organizational goals.
B. HORIZONTAL(ORGANIC) ORGANIZATIONS:
Technology, film producing, large construction and collegial organizations are involved in small batch production. For this kind of production there is and needs to be more ongoing verbal communication within and among the basic teams which are the Operating Core of the organization. In this situation, the organization is a network of persons and teams. There is an informal work and social atmosphere and tasks are more complex. The authority to control tasks is delegated to the teams actually doing the work, rather than falling to a hierarchy of middle level managers, each with a defined set of organizational units for which they are responsible.
IN OTHER WORDS: Small batch production basically focuses on products which are more customized rather than mass-produced, requiring constant adjustment and problem-solving relating to exceptions (whether easy or hard to analyze). This necessitates a less hierarchical, team-centered form of production and decision-making. Decision-making is more decentralized, and is located at the point where work is done. Information flows horizontally.
The nature of the product in terms of difficult-to analyze exceptions thus requires organic structure and the associated types of decision-making. The organization is a network of persons and teams. There is an informal atmosphere and the tasks faced by each team and person are more complex than in a vertical organization with lots of division of labor. There is a lot of verbal communication, a large portion of which is focused on mutual adjustment as well as production. In fact, there is more need than in a vertical organization for face-to-face contact for purposes of production and coordination.
The organization is thus by necessity structured into smaller teams of professionals or people with the expertise, experience, and training to make decisions in a collective way, without constantly referring to higher level decision makers.
THERE IS LITTLE HIERACHY IN THIS KIND OF ORGANIZATION BECAUSE OF THE VOLUME OF GOODS AND SERVICES PRODUCED, THE CUSTOMIZED NATURE OF THE GOODS AND SERVICES PRODUCED, AND THE CENTRAL IMPORTANCE OF THE TEAMS OF CORE WORKERS WHO MAKE ALL THE CRITICAL PRODUCTION DECISIONS AND ADJUSTMENTS.
reading 2: Coordinating health care services
Coordinating Health Care Services
In the United States, 125 million people are living with chronic illness, disability, or functional limitation. The nature of modern medicine requires that these patients receive assistance from a number of different care providers.
Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care physicians and five specialists each year, in addition to accessing diagnostic, pharmacy, and other services. Patients with several chronic conditions may visit up to 16 physicians in a year.2 Care among multiple providers must be coordinated to avoid wasteful duplication of diagnostic testing, perilous polypharmacy, and confusion about conflicting care plans.
The particularities of American health care, with its pluralistic delivery system that features large numbers of small providers, magnify the number of venues such patients need to visit.
Care must be coordinated among primary care physicians, specialists, diagnostic centers, pharmacies, home care agencies, acute care hospitals, skilled nursing facilities, and emergency departments.
Within each of these centers, a patient may be touched by a number of physicians, nurses, medical assistants, pharmacists, and other care-givers, who also need to coordinate with one an-other.
Given this level of complexity, the coordination of care among multiple independent providers becomes an enormous challenge.
Care coordination has been defined as “the deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” It is the conscious effort by two or more health care professionals to facilitate and coordinate the appropriate delivery of health care services for a patient. Care coordination activities promote a holistic and patient-centered approach to care to help ensure that a patient’s needs and goals are understood and shared among providers, patients, and families as a patient moves from one healthcare setting to another.
Not only is care co-ordination needed among multiple providers, but coordination is also required between providers and patients and their families. Particularly for young children and elderly patients, the number of coordination relationships can multiply geometrically in the not-unusual case of three different provider organizations (with several caregivers in each organization) having to interact with a patient plus three distinct family members.
Care coordination is required when traditional continuity of care — the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease -- is lacking.
Continuity and fragmentation of care can be viewed as opposite ends of a spectrum. In unusual cases in which continuity is nearly total, coordination is rarely needed. In the most common situation in which continuity is limited and care is fragmented, coordination is essential. This report assesses the quality of care coordination, lists barriers to coordinated care, and discusses some solutions to improve care coordination.
COORDINATING CARE – HOW ARE WE DOING?
Recent research strongly suggests that failures in the coordination of care are common and can create serious quality concerns. READING 3, SLIDE 4 lists several studies documenting some of these problems.
For example, referrals from primary care physicians to specialists often include insufficient information, and consultation reports from specialists back to primary care physicians are often late and inadequate.
When patients are hospitalized, their primary care physicians may not be notified at the time of discharge, and discharge summaries may contain insufficient information or never reach the primary care practice at all.
The studies listed in READING 3 SLIDE 4 do not comprise a rigorous review of the literature but provide examples of the kinds of difficulties in care coordination that patients and their families and caregivers face. In addition to research studies, the voices of patients and their families remind us that the coordination of their care among multiple providers is often flawed.
The rapid increase in health care spending in the United States over the past two decades and its anticipated growth in the coming years can be tied inextricably to the increasing number of people with multiple chronic conditions.
COORDINATING CARE – STRATEGIES FROM THE FEDERAL MEDICARE PROGRAM:
Medicare beneficiaries are especially likely to have multiple clinical conditions, with two-thirds of Medicare spending attributed to patients with five or more chronic conditions.
Medicare Fee-For-Service (FFS) spending, in particular, accounts for over three quarters of the total Medicare spending.
Gaps in the coordination of care for these chronically ill patients, including inadequate transitional care from hospital to home and insufficient management of multiple medications, often result in poor care quality, increased hospital admissions, and growing health care expenditures in Medicare.
Care coordination can be defined broadly as the conscious effort by two or more health care professionals to facilitate and coordinate the appropriate delivery of health care services for a patient.
However, measuring the effectiveness of care coordination activities to reduce spending and improve the quality of care can be challenging due to limited implementation time, high intervention costs, and varying outcome measures and study populations. Many demonstrations and studies have reported little or no change in the total health care spending.
Illustrative examples of care coordination activities that do, in fact, prove promising for reducing the spending and improving the quality of care in Medicare Fee-For-Service patients are in the following 2 categories:
Transitional Care refers to the management of a patient’s care during a transition from one care setting to another, typically from the hospital to the home. The Medicare Care Transitions Intervention program and the Transitional Care Model are two specific transitional care approaches that have been implemented in a variety of settings, resulting in reduced readmission rates and, subsequently, reduced hospitalization costs.
Example 1: Doing a Better Job of Coordinating Transitional Care.
To streamline care transitions from hospital to home, reduce rehospitalization rates, and cut Medicare spending, the Medicare Care Transitions Intervention program incorporates coaching and home visits by professional care coordinators. The four-week program, which was developed by Dr. Eric Coleman at the University of Colorado Medical School, utilizes these designated Transition Coaches to train complex patients and their family caregivers how to manage their own care. By leveraging existing providers, including nurse practitioners, nurses, and social workers, to serve as Transition Coaches, the limited workforce of the primary care system can reach a large number of Medicare beneficiaries.
Many chronically ill patients and their caregivers already serve as their own primary care coordinators every day, but they lack the skills, tools, and confidence for effective care management and communication of their care preferences and clinical goals. A number of qualitative studies have reported that patients are often unprepared for the next care setting, receive conflicting advice from providers, are often unable to get in touch with the appropriate-ate provider, and have little input into their care plan. Under the Care Transitions Intervention model, the Transitions Coach makes one home visit and three phone calls to the assigned patient over 30 days, and provides a variety of other services, ranging from acting out a role-play of the next medical visit to creating an accurate medication list to support medication reconciliation and adherence.
Medication Management Programs have helped reduce health care spending in a variety of health plans. Sponsors of the optional drug benefit, or Part D, of Medicare are required to offer medication therapy management services to enrollees meeting the eligibility criteria. Recent evidence, however, suggests that medication management should be connected comprehensively to the clinical services provided and focused on improving outcomes measured by physician and other providers during patient visits.
Coordination issues addressed by effective Medication Management Programs include improper drug selection, incorrect drug dosages, and negative drug interactions when a patient is taking multiple drugs, often for multiple chronic conditions.
An important component of improving the quality of care and reducing costs is ensuring through active management of medications that patients are getting the most benefits from their drug therapies. Discrepancies among the various medications and miscommunication between providers and patients lead to frequent medication-related problems and gaps in care coordination, which numerous health plans and systems have attempted to close through medication management programs.
Example 2: Doing a Better Job of Medication Management.
Since the mid-1990s, the Veterans Health Administration (VHA) has acknowledged the importance of medication management and has granted prescriptive privileges to pharmacists through Scope of Practice (SOP) arrangements. Currently, more than 2,200 VHA pharmacists practice under an SOP through which they collaborate with primary and specialty care physicians with the intention of achieving the optimal medication benefits for their patients. This arrangement often includes the authority of pharmacists to prescribe medications or suggest medication changes for patients. Similarly, the Fairview Health System in Minnesota has implemented an effective medication program, in which clinical pharmacists participate in over 20 collaborative practice agreements to manage patients’ medications.49 Since its creation in 1997, the comprehensive medication management program has provided care for more than 15,000 patients and resolved nearly 80,000 drug therapy problems.
