Care Coordination and Interoperable Health IT Systems

1. Care Coordination and Interoperable Health IT Systems Unit 1: Overview of Care Coordination Lecture a – What is Care Coordination? This material (Comp 22 Unit 1) was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Overview of Care CoordinationLecture a – Learning Objectives • Objective 1: Define care coordination effectiveness (Lecture a) • Objective 2: Explain the purposes for care coordination (Lecture a) • Objective 3: Discuss various models of Care Coordination (Lecture b) • Objective 4: Compare care coordination roles and responsibilities in the post-Affordable Care Act models of care across the care continuum (Lecture b) • Objective 5: Discuss Specialty care coordination (Lecture c) • Objective 6: Discuss Long term care/post-acute care (aka “The Last Mile”) (Lecture c) • Objective 7: Identify stakeholders in care coordination (Lecture c)

3. Overview of Care Coordination Care Coordination involves: • Patient care activities • Sharing information/Communication • Using information • Patient’s needs and preferences • Care transitions

4. Case Example: Mr. Andrews Creative Stall., CC BY NC-SA 3.0. Home meal staffer notices Mr. Andrews looks very ill, and calls ambulance Mr. Andrews cannot recall meds Hospital contacts PCP PCP provides history and contact info for Mr. Andrew’s specialists Hospital nurse reviews new prescriptions with Mr. Andrews Daughter is informed and picks up medications Hospital sends PCP Mr. Andrew’s record upon discharge Adapted from full case example at AHRQ.gov • Congestive Heart Failure • Diabetes • Sees: PCP, nephrologist, and cardiologist • 2 pharmacies • Home meals 5 days/week • Daughter works full time

5. Evidence–Based Care Coordination • Allows for seamless transitions across the health care continuum • Improves outcomes • Reduces errors and redundancies • Decreases health care costs

6. Care Coordination’s Purpose is to Meet Needs • Develop collaborative health-partnership relationships • Integrate health IT systems • Ensure multidisciplinary health teams’ optimum collaboration

7. Care Coordination Aims for Continuity • Provide continuity of care • Achieve positive patient health and experience outcomes • Provide necessary access to care continuity information

8. Care Coordination Facilitates Appropriate Care • Thoughtful identification of key services providers in the community • Deliberate organization of patient care activities between participants involved in a patient’s care • http://www.safetynetmedicalhome.org/

9. Care Coordination Takes a Team • the family • physician specialists • hospitals • emergency departments and emergency physicians specialists • nursing homes • skilled care facilities • rehabilitation facilities • home health and community based services • home attendants • hospice programs • facility case managers • discharge planners • care coaches • care transitions navigators • mental health providers • pharmacists • community health workers • community resource teams • payer-based service coordinators • & others

10. Care Coordination from the Patient’s Perspective “I just want my doctors to talk to each other” Christine Bechtel, National Partnership for Women and Children

11. The HIPAA Privacy Rule • Health Insurance Portability and Accountability Act – HIPAA • Security Rule - Provides technical guidance for protected health information security • Privacy Rule - Provide guidance ensuring protected health information privacy

12. Care Coordination and Protected Health Information (PHI) • It is possible to provide coordinated care AND protect privacy! • Protect and provide necessary and timely protected health information (PHI) – care coordination is treatment (45 CFR 164.506(c)(2)) • Quality and safety improvement in care coordination and health care delivery

13. Case Example: Julie and Paul Boatman, E., CC BY NC-SA 3.0 John’s pediatrician’s practice adopted care coordination John’s care coordinator connects family to behavior health specialist, legal specialist, pharmacist, and social worker All professionals update the same electronic medical record (EHR) EHR sends reminders to care coordinator to follow up with John’s family Adapted from full case example at FamiliesUSA.com • Julie just lost her job • Children enrolled in Children’s Medicaid • John, their son, has severe asthma with expensive medications • 2-bedroom apartment has some mold

14. Care Coordination Supports the Triple Aim • Improving the patient experience of care • Improving the health of populations • Reducing per capita cost of health care (Berwick et al., 2008) 1.1 Figure (Collaborative Family Healthcare Association, 2014)

15. Whole–Person Comprehensive Care Coordination • Comprehensive care • Collaborative self-management support • Emphasis on care needs in multiple settings across the care continuum and community

16. Whole–Person Centered Care Coordination • New organizations working together, i.e., transportation, provider, and education • New information gathering and data needed.

17. Whole–Person Care: The Patient-Centered Medical Home • Primary care physician coordinates via • Registries • Information technology, • Health information exchange, and • Other means https://uthealthservices.com/about/pcmh.htm

18. Care Coordination for Complex Conditions • Special needs frail pediatric patients • Chronically ill patients • Patients requiring high health care utilization

19. Case Example: Ms. H Creative Stall., CC BY NC-SA 3.0. PCP has met with the director of a Mental Health Center, and refers Ms. H to that center Director had referred specific psychiatrist to PCP’s practice PCP postpones hypertensive drugs to treat Ms. H’s depression first PCP office uses e-referral system to schedule Ms. H’s appointment with psychiatrist at the Center Center calls Ms. H when she misses appointment to reschedule Mental Health Center populates PCP’s electronic health records Adapted from full case example at The Commonwealth Fund • Type 2 diabetes, weight gain, and major depression • Currently sees a PCP • HbA1c of 8.9% • Blood pressure 148/88

20. The Range of Care Coordination • Variable components across states and systems of care • Range of professional and non-professional staff supported by various payers and forms of payment Silow-Carroll et al. (2013)

21. Information Used in Care Coordination • Demographics • Patient-generated health information • Clinical documentation notes • Medication management information • Care plans • Other

22. Care Coordination System Essentials • PHI and technology should be standardized and consistent • Health IT systems’ capabilities should be well aligned with the clinicians’ priorities • Interoperable systems to share information • Adequate financial support and health IT workforce expertise

23. Ensuring Care Coordination • Cooperative alliances with essential health care services • Processes that ensure collaboration, coordination, and communication between PCP team leader and patient

24. Unit 1: Overview of Care CoordinationSummary – Lecture a – What is Care Coordination? • Care coordination requires collaboration and communication between the primary care physician team leader, care team, and the patient • Care coordination is successful when the right information is available, supported by health IT systems, for decision-making

25. Unit 1: Overview of Care Coordination References – Lecture a References Antonelli R.C., McAllister J.W., Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009 Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood).2008;27(3):759–769 Bodenheimer, T. (2008). Coordinating care-a perilous journey through the health care system. New England Journal of Medicine, 358(10), 1064. S. Silow Carroll, J. N. Edwards, and D. Rodin, Aligning Incentives in Medicaid: How Colorado, Minnesota, and Colorado Are Reforming Care Delivery and Payment to Improve Health and Lower Costs, The Commonwealth Fund, March 2013. TransforMED. (n.d.). Retrieved March 04, 2016, from http://www.aafp.org/about/affiliated-organizations/aff-orgs/transformed.html Original TransforMED website closed, legacy materials hosted by the American Academy of Family Physicians. Wagner, E., MD. (n.d.). The Chronic Care Model. Retrieved March 04, 2016, from http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model

26. Unit 1: Overview of Care Coordination References – Lecture a (Cont’d – 1) References Agency for Healthcare Research and Quality. (2014). Care Coordination Measurements Atlas Chapter 2: What is Care Coordination?. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/chapter2.html FamiliesUSA. (2013). The Promise of Care Coordination: Transforming Health Care Delivery. Retrieved from:http://familiesusa.org/sites/default/files/product_documents/Care-Coordination.pdf The Commonwealth Fund. (2011). Reducing Care Fragmentation: A Toolkit for Coordinating Care. Retrieved from http://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf Images Slide 3: McMahon, K. (2010). Maze [Online Image]. Retrieved March 8, 2016 from https://www.flickr.com/photos/katiemcmahon/4689733531/in/photolist-89q7oF-tSbpp-p65cS-4V5GTp-amaByJ-cp37M-m8Wps-bQjGun-cKEMV-74Vx2F-89o4x5-H4kjU-asgG-9uHvkJ-9gj2Fq-aqiePB-4sWgYm-6auvvj-dT6Xgx-7mdtmH-8JakbA-4rXpp7-8kwiv-5zAavx-5zAacV-aAxuyP-3CZo9a-dUwDmk-SKr7B-6iCeTS-7j2XDW-5jGFFE-asgF-6ECAa-cYMgYb-3yHCr-gYksw7-68kCt8-2Eyfcb-9gfWRH-8JajaJ-8J7ckg-5zA9Xx-5yjgew-ptMdeG-cYMgVb-8J7eeK-ahH8pa-vWC24-aCopiV

27. Unit 1: Overview of Care Coordination References – Lecture a (Cont’d – 2) Images Slide 5: Creative Stall via The Noun Project. (n.d.). Old Man [Online Image]. Retrieved March 9, 2016 from https://thenounproject.com/creativestall/collection/people-solid-icons/?q=old%20man&i=144370 Slide 13: Boatman, E. (n.d.). Family Practice [Online Image]. Retrieved March 9, 2016 from https://thenounproject.com/search/?q=grandmother&i=144351 Slide 20: Creative Stall via The Noun Project. (n.d.). Old Lady [Online Image]. Retrieved March 9, 2016 from https://thenounproject.com/search/?q=grandmother&i=144351 Charts, Tables, Figures 1.1 Figure: Collaborative Family Healthcare Association,. (2014). Triple Aim of Care Coordination

28. Unit 1: Overview of Care CoordinationLecture a – What is Care Coordination? This material was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006.