Thursday, April 11, 2013

Care Coordination for Patients with Chronic Condition

Historically, public and private health organizations have tried and continue trying to improve the quality of care for patients with chronic conditions.   The following statistics were published by the Center for Disease Control and Prevention: 

7 out of 10 deaths among Americans each year are from chronic diseases. Heart disease, cancer and stroke account for more than 50% of all deaths each year. 

In 2005, 133 million Americans – almost 1 out of every 2 adults – had at least one chronic illness. 

Obesity has become a major health concern. 1 in every 3 adults is obese and almost 1 in 5 youth between the ages of 6 and 19 is obese (BMI ≥ 95th percentile of the CDC growth chart). 

About one-fourth of people with chronic conditions have one or more daily activity limitations. 
Arthritis is the most common cause of disability, with nearly 19 million Americans reporting activity limitations. 

Diabetes continues to be the leading cause of kidney failure, non-traumatic lower-extremity amputations, and blindness among adults, aged 20-74.

Unfortunately this statistics may not change for the better, if not, increase affecting million more Americans.  A chronic condition is the state of the disease that usually will last for more than one-year without significant improvement and debilitating the individual in many different functions of his life, physically and mentally.  To care for an individual with a chronic condition, it requires extensive care coordination and follow-up. 

In another statics release by the Improving Chronic Illness Care, a national organization, show that more than 145 million people, or almost half of all Americans, live with a chronic condition. That number is projected to increase by more than one percent per year by 2030, resulting in an estimated chronically ill population of 171 million.

Almost half of all people with chronic illness have multiple conditions. As a result, many managed care and integrated delivery systems have taken a great interest in correcting the many deficiencies in current management of diseases such as diabetes, heart disease, depression, asthma and others.

Those deficiencies include:
Rushed practitioners not following established practice guidelines
Lack of care coordination
Lack of active follow-up to ensure the best outcomes
Patients inadequately trained to manage their illnesses 

In order to address the mentioned “deficiencies” in the management of disease, care coordination takes the center as a promising evidence-based best practice in order to help address deficiencies.   

Care coordination has many different definitions and functions, it depends on patients’ demographics and specific health care needs.  It is also known that care coordination is not a single approach such as the primary care provider coordinating all the care and services for his/her patients, but also takes an integrated team approach. 

The following is a care coordination definition that captures the meaning and functions of care coordinationthe deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.”  In other words, care coordination facilitates the exchange of information between providers such as primary care provider and specialist, it involves the patients and family in the process of care treatment, and decision-making, coordinates and follow-up on referrals, and facilitates the learning of disease management and independence.

In reviewing the literature in Care Coordination, we encountered this Care Coordination Model that integrates four key areas in order to achieve effective care coordination.  It is important to note that all four steps should be linked to each other in order to achieve “high-level” change in the practice. 

Change Package

Practices wanting to improve the coordination of their care should consider making changes to practice systems and processes consistent with four elements—accountability, relationships and agreements, patient support, and connectivity. 

These four areas represent high-level “change concepts,” which the Institute for Healthcare Improvement defines as “general ideas…that can be adapted to make specific changes that lead to improvement in many processes and clinical areas”.  In aggregate they describe the “change package” for better care coordination.  But, to be useful, suggested changes to a practice must be more specific.

The following is a breakdown of what each area in the Care Coordination Model, as they apply to each change concept, and the specific activities involved in making the key change.  For more information on this model, visit ICIC at 

Accountability Key Changes - Decide as a primary care clinic to improve care coordination.   Develop a tracking system.  

Patient Support Key Changes - Organize a practice team to support patients and families. 

Relationships & Agreements Key Changes - Identify, develop, and maintain relationships with key specialist groups, hospital, and community agencies.  Develop agreements with these key groups, hospital, and agencies. 

Connectivity Key Changes - Develop and implement an information transfer system. 

It is important to keep all four key areas in mind when planning for improving care coordination at your practice.  Each step should be planned, analyzed, strategized, and implemented with realistic obtainable goals.  It is highly suggested that if it is your first time improving care coordination at your practice that you set short term goals and long term goals for measurement.  You can also use another tool to track your progress in the care coordination improvement “initiative” such as Plan, Do, Study, and Act breakthrough series pioneered by the Institute for Healthcare Improvement (IHI).  This tool can help out the team to document test changes, track team progress, and observe changes.  It is important to set simple and short terms objectives when using the PDSA. 

Once the practice has decided to improve care coordination (Accountability area), the PDSA should be used, but first an aim statement should be drafted to provide specific focus to the team.

Set short-term goals, set measureable outcomes, assign team member’s role, and identify who will keep track and document changes.

The following is a test change sample: 
 Plan, Do, Study, and Act 

Change or Idea evaluated: Submit letter of request to Director of Health Information Management for approval. 

Objective for this PDSA Cycle: To obtain an approval from the director of health information management in order to integrate care notebook tools. 

What question(s) do we want to answer with this PDSA cycle? Are there any protocols processes that need to be approved before the director of health information management makes a final decision? 

Plan: Plan to answer questions - Primary Investigator (PI) sent a memo to the director of health information management, requesting approval of the care book integration into the practice system of care. 

Tracking (data collection) 
Collect and track the number of disseminated care books to current and new patients during visits with specialist.  A receipt will be enclosed the care book for the specialist and the medical home provider to sign as proof of receiving and reviewing the care book.  

The second part of the test is to track the number of care books scanned into the patient’s electronic medical records. 


We predict that the approval process by the director of health information management may take up to 3 months.  We also predict that clinic staff will need our guidance in implementing the tools with new patients. 

Do: We predict extensive staff training in utilizing the tools with patients.  We are targeting to begin transition process by the end of August. 

Study: The director of health information management approve PI request within 45 days of submitting memo.

The care book was distributed the first 10 families within two months.  The receipt was tracked and only 6 specialist and 4 medical home providers signed it. 

Act: The receipt was removed from the care book.  Practice staff will continue distributing the care book to new patients.  Staff need more training in how to work with families around the care book. 

In conclusion, improving care coordination at your practice is a process that should have well defined steps, staff roles, resources, goals, and a timeframe.  People with chronic conditions need the quality of care, but at the same time need to gain control and manage within the best of their ability the disease.  The practice team should decide which tools is the best for them to use, keeping in mind that taking small steps and testing short term changes can be efficient and simple to manage.  Applying quality improvement models can help close the gap in the care of people with chronic conditions as well lower the cost of health care, minimizing the number of visits to the ER, and obtain optimum quality of care. 
Improving Chronic Illness Care (ICIC) 
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20:64-78. 
Improving Chronic Illness Care (ICIC) 
Institute for Healthcare Improvement (IHI) 
The Epilepsy Foundation of Metropolitan New York.  Project Access, 2010. 
About the Author:
Helen Dao, MHA
A Public Health Consultant
Dao Management Consulting Services, Inc.
A Public Health Company Connecting Providers and Communities