|Establish Accountability or Negotiate Responsibility
||NQF: Communication domain includes – all medical home team members work within the same plan of care and are measurably coaccountable for their contributions to the shared plan and achieving the patient's goals.
||Antonelli: Care coordination competency – communicates proficiently; care coordination function – manages continuous communication.
NQF: Framework domain – Communication available to all team members, including patients and family.
||Coiera: All information exchanged in health care forms a “space”; the communication space is the portion of all information interactions that involves direct interpersonal interactions, such as face-to-face conversations, telephone calls, letters, and email.
||MPR: Care coordination activity – send patient information to primary care provider.
NQF: Communication domain includes – availability of patient information, such as consultation reports, progress notes, test results, and current medications to all team members caring for a patient reduces the chance of error.
||Antonelli: Care coordination function – supports/facilitates care transitions.
CMS Definition of Case Management: §440.169(c) Case management services are defined for transitioning individuals from institutions to the community.
NQF: Framework domain – transitions or “hand-offs” between settings of care are a special case because currently they are fraught with numerous mishaps that can make care uncoordinated, disconnected, and unsafe. Some care processes during transition deserve particular attention, including involvement of team during hospitalization, nursing home stay, etc.; communication between settings of care; and transfer of current and past health information from old to new home.
|Assess Needs and Goals
||Antonelli: Care coordination function – completes/analyzes assessments.
CMS Definition of Case Management: §440.169(d) Case management includes assessment and periodic reassessment of an eligible individual to determine service needs, including activities that focus on needs identification, to determine the need for any medical, educational, social, or other services.
MPR: Care coordination activity – assess patient's needs and health status; develop goals.
|Create a Proactive Plan of Care
||Antonelli: Defining characteristic of care coordination – proactive, planned and comprehensive; care coordination function – develops care plans with families; facile in care planning skills.
CMS Definition of Case Management: §440.169(d)(2) Case management assessment includes development and periodic revision of a specific care plan based on the information collected through an assessment or reassessment that specifies the goals and actions to address the medical, social, educational, and other services needed by the eligible individual, including activities such as ensuring the active participation of the eligible individual and working with the individual (or the individual's authorized health care decisionmaker) and others to develop those goals and identify a course of action to respond to the assessed needs of the eligible individual.
MPR: Care coordination activity – develop a care plan to address needs.
NQF: Framework domain – Proactive Plan of Care and Followup is an established and current care plan that anticipates routine needs and actively tracks up-to-date progress toward patient goals.
|Monitor, Follow Up, and Respond to Change
||Antonelli: Care coordination function – manages/tracks tests, referrals, and outcomes.
CMS Definition of Case Management: §440.169(d)(1) Case management assessment includes periodic reassessment to determine whether an individual's needs and/or preferences have changed. §440.169(d)(2) Case management includes monitoring and followup activities, including activities and contacts that are necessary to ensure that the care plan is effectively implemented and adequately addresses the needs of the eligible individual. If there are changes in the needs or status of the individual, monitoring and followup activities include making necessary adjustments in the care plan and service arrangements with providers.
MPR: Care coordination activities – monitor patient's knowledge and services over time; intervene as needed; reassess patients and care plan periodically.
NQF: Plan of Care domain includes – followup of tests, referrals, treatments, or other services.
|Support Self-Management Goals
||Antonelli: Defining characteristic of care coordination – promotes self-care skills and independence; care coordination function – coaches patients/families.
MPR: Care coordination activity – educate patient about condition and self-care.
NQF: Plan of Care domain includes – self-management support.
|Link to Community Resources
||Antonelli: Care coordination competency – integrates all resource knowledge.
CMS Definition of Case Management: §440.169(d)(2) Case management includes referral and related activities (such as scheduling appointments for the individual) to help an individual obtain needed services, including activities that help link eligible individuals with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.
MPR: Care coordination activity – arrange needed services, including those outside the health system (meals, transportation, home repair, prescription assistance, home care).
NQF: Plan of Care domain includes – community services and resources. The Plan of Care includes community and nonclinical services as well as traditional health care services that respond to a patient's needs and preferences and contribute to achieving the patient's goals.
|Align Resources with Patient and Population Needs
||MPR: Care coordination activity – arrange needed services, including those within the health system (preventive care with primary care provider; specialist visits; durable medical equipment; acute care).
NQF: A principle of care coordination is that care coordination is important to all patients, but some populations are particularly vulnerable to fragmented, uncoordinated care on a chronic basis, including (not mutually exclusive): children with special health care needs; the frail elderly; persons with cognitive impairments; persons with complex medical conditions; adults with disabilities; people at the end of life; low-income patients; patients who move frequently, including retirees and those with unstable health insurance coverage; and behavioral health care patients.
|Teamwork focused on Coordination
||Antonelli: Care coordination competency – applies team-building skills; care coordination function – facilitates team meetings.
||NQF: Framework domain – Health Care Home is a source of usual care selected by the patient (such as a large or small medical group, a single practitioner, a community health center, or a hospital outpatient clinic).
||See elements of CMS case management definition mapped under other domains.
||MPR: Care coordination activity – review medications.
NQF: Transitions or “hand-offs” domain includes medication reconciliation.
|Health IT-enabled Coordination
||Antonelli: Care coordination competency – adept with information technology; care coordination function – uses health information technology.
NQF: Framework domain – information systems – the use of standardized, integrated electronic information systems with functionalities essential to care coordination is available to all providers and patients.