2012 National Healthcare Quality Report

Chapter 6. Care Coordination

Health care in the United States is often fragmented. Clinical services are frequently organized around small groups of providers who function autonomously and specialize in specific symptoms or organ systems. Therefore, many patients receive attention only for individual health conditions rather than receiving coordinated care for their overall health. For example, the typical Medicare beneficiary sees two primary care providers and five specialists each year (Bodenheimer, 2008). Communication of important information among providers and between providers and patients may entail delays or inaccuracies or fail to occur at all.

Care coordination is a conscious effort to ensure that all key information needed to make clinical decisions is available to patients and providers. It is defined as the deliberate organization of patient care activities between two or more participants involved in a patient's care to facilitate appropriate delivery of health care services (Shojania, et al., 2007). Care coordination is multidimensional and essential to preventing adverse events, ensuring efficiency, and making care patient centered (Powell-Davies, et al., 2008).

Patients in greatest need of care coordination include those with multiple chronic medical conditions, concurrent care from several health professionals, many medications, extensive diagnostic workups, or transitions from one care setting to another. Effective care coordination requires well-defined multidisciplinary teamwork based on the principle that all who interact with a patient must work together to ensure the delivery of safe, high-quality care.

In early 2011, the Partnership for Patients was created to improve the quality, safety, and affordability of health care for all Americans. One of the two major goals of this public-private partnership is to heal patients without complications arising. This goal specifically ties to care coordination by seeking to decrease preventable complications during transitions from one care setting to another. The objective is to decrease all hospital readmissions by 20% overall by the end of 2013 (compared with 2010).

One example of the Federal Government's efforts to support care coordination is the Health Resources and Services Administration's initiative "Enhancement & Evaluation of Existing Health Information Electronic Network Systems for PLWHA (People Living With HIV/AIDS) in Underserved Communities." Begun in 2007, the initiative funded six demonstration sites throughout the Nation for up to 4 years.i

Another more recent funding opportunity also offered by HRSA is "Systems Linkages and Care Initiative to High Risk Populations Evaluation and Technical Assistance Center." This initiative promotes the development of innovative strategies to successfully integrate different components of the public health system into quality HIV care of hard-to-reach populations who have never been in care.

The Agency for Healthcare Research and Quality (AHRQ) intends this chapter to be the leading step in the evolving national discussion on measuring care coordination. Furthermore, AHRQ hopes that this chapter will stimulate productive discussions in the area of care coordination, including development and use of valid, reliable, and feasible quality measures.

Importance

Morbidity and Mortality

  • Care coordination interventions have been shown to:
    • Reduce mortality among patients with heart failure.
    • Reduce mortality and dependency among patients with stroke.
    • Reduce symptoms among patients with depression and at the end of life.
    • Improve glycemic control among patients with diabetes (Shojania, et al., 2007).

Cost

  • Care coordination interventions have been shown to:
    • Reduce hospitalizations among patients with heart failure.
    • Reduce readmissions among patients with mental health conditions.
    • Be cost-effective when applied to treatment of depression (Shojania, et al., 2007).

Measures

The National Strategy for Quality Improvement in Health Careii identified care coordination as one of six national priorities for health care. The vision is health care providers, patients, and caregivers all working together to "ensure that the patient gets the care and support he needs and wants, when and how he needs and wants it." While measurement of care coordination is at an early stage in development, key goals include coordinating transitions of care, reducing hospital readmissions, communicating medication information, and reducing preventable emergency department visits.

Measures reported in this chapter are organized around these goals:

  • Transitions of care:
    • Adequate hospital discharge information.
  • Readmissions:
    • State variation: Readmissions for congestive heart failure.
  • Integration of information:
    • Provider asking about medications from other doctors.
    • Electronic exchange of medication information.
  • Children with special health care needs (CSHCN):
    • CSHCN with effective care coordination.
    • CSHCN with a medical home.

Findings

Transitions of Care

As health care conditions and needs change, patients often need to move from one setting to another. These transitions of care place patients at heightened risk of adverse events. Important information may be lost or miscommunicated as responsibility is delivered to new parties.

Management: Complete Written Discharge Instructions

Effective care coordination begins with ensuring that accurate clinical information is available to support medical decisions by patients and providers. A common transition of care is discharge from the hospital. Giving patients and caregivers self-management support after discharge has been shown to reduce readmissions to the hospital and lower costs (Coleman, et al., 2006).

Discharge from a hospital typically indicates improvement in a patient's condition so that the patient no longer requires inpatient care. It also means that the patient and family must resume responsibility for the patient's daily activities, diet, medications, and other treatments. The patient also needs to visit his or her personal doctor and know what to do if his or her condition deteriorates. Written discharge instructions are critical to help ensure that a patient receives the information needed to stay healthy after leaving the hospital.

  Figure 6.1. Hospitalized adult patients with heart failure who were given complete written discharge instructions, by age and gender, 2005-2010

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Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program, 2005-2010.
Denominator: Hospitalized adult patients with a principal discharge diagnosis of heart failure.
Note: Complete written discharge instructions needed to address all of the following: activity level, diet, discharge medications, followup appointment, weight monitoring, and actions to take if symptoms worsen.

  • From 2005 to 2010, the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved from 57.4% to 89.7% (data not shown).
  • Improvements were observed among all age and gender groups (Figure 6.1).
  • Statistically significant differences by age and gender were not observed.
  • The 2010 top 5 State achievable benchmark was 94%.iii At the current 6% annual rate of increase, this benchmark could be attained overall and by all age and gender groups in less than a year.

Also, in the NHDR:

  • Improvements were observed among all racial and ethnic groups.

Hospital Readmissions

State Variation: Readmissions for Congestive Heart Failure

After discharge from the hospital for a chronic condition such as congestive heart failure (CHF), many patients will be rehospitalized. Rehospitalization signals a worsened state of illness and may reflect care that is not optimally coordinated. Rehospitalization also has significant cost implications since it is much more resource intensive than outpatient treatment.

Although not all rehospitalizations for CHF can be prevented, the risk of rehospitalization may increase when patients do not follow their discharge instructions. After discharge, patients need to take their medications regularly, adhere to recommendations related to diet and activity, monitor their weight, and look for signs and symptoms that their CHF is not under good control.

When patients do not receive written discharge instructions that they understand, they may be less able to follow them. In addition, postdischarge care should be coordinated with the patient's primary care physician. Patients will need to arrange followup visits with their primary care physician, who can adjust medications early to help prevent rehospitalization.

  Figure 6.2. State variation: Readmissions for congestive heart failure, by comparison to the national average, 2008-2010

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Source: Centers for Medicare & Medicaid Services, HospitalCompare, 2008-2010, accessed July 25, 2012.
Note: National average=25%. Calculation of the 30-day readmission rates are adjusted for patient characteristics, including the patient's age, gender, past medical history, and other diseases or conditions (comorbidities).

  • With the exception of several States, the eastern United States had higher percentages of hospitals with readmission rates worse than the national average (25%; Figure 6.2).
  • The central United States had moderate percentages of hospitals with readmission rates worse than the national average.
  • The north central and northwestern States were more likely to have no hospitals with readmission rates worse than the national average.

Integration of Information

Patients often seek care from many providers. Medical information generated in different settings may not be sent to a patient's primary care provider. Actively gathering and managing all of a patient's medical information is an important part of care coordination. Tasks include ensuring that patients are informed of important findings such as test results, primary care doctors are informed of care from specialists, and providers within a practice have access to needed information.

Management: Provider Asking About Medications From Other Doctors

Different providers may prescribe medications for the same patient. Patients are responsible for keeping track of all their medications, but medication information can be confusing, especially for patients on multiple medications. When care is not well coordinated and some providers do not know about all of a patient's medications, patients are at greater risk for adverse events related to drug interactions, overdosing, or underdosing. In addition, providers need to periodically review all of a patient's medications to ensure that they are taking what is needed and only what is needed. Medication reconciliation has been shown to reduce both medication errors and adverse drug events (Whittington & Cohen, 2004).

Medication information generated in different settings may not be sent to a patient's primary care provider. In the absence of communication from other providers, the patient is the primary source of medication information. Actively gathering and managing all of a patient's medical information is an important part of care coordination.

  Figure 6.3. People with a usual source of care whose health provider usually asks about prescription medications and treatments from other doctors, by family income and insurance (adults under age 65), United States, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population who report a usual source of care.

  • From 2002 to 2009, the percentage of people with a usual source of care whose health provider usually asked about prescription medications and treatments from other doctors improved from 75.1% to 79.3% (data not shown).
  • In 2009, there were no statistically significant differences by family income or insurance (Figure 6.3).

Also, in the NHDR:

  • In 2009, there were no statistically significant differences by education or perceived health status.

Structure: Electronic Exchange of Medication Information

Ideally, information about medications prescribed for a patient by one provider would be available to all providers taking care of that patient. One way to exchange this information efficiently is to build this function into health information technologies. The American Hospital Association recently surveyed hospitals about their use of health information technologies. Questions about whether a hospital electronically exchanged patient information on medication history with other providers were included, and 2,112 hospitals responded.

  Figure 6.4. Hospitals with electronic exchange of patient information on medication history, by ownership and bed size, 2009 and 2010, electronic exchange with hospitals outside their system (top) and electronic exchange with ambulatory providers outside their system (bottom)

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Source: American Hospital Association Annual Survey Information Technology Supplement, 2009 and 2010.

  • In 2010, 19.4% of hospitals electronically exchanged patient information on medication history with hospitals outside their system, up from 13.4% in 2009. Also, 32.1% of hospitals exchanged information with ambulatory providers outside their system, up from 28.2% in 2009 (Figure 6.4).
  • Federal hospitals were most likely to have electronic exchange with hospitals outside their system, followed by non-Federal, nonprofit, and for profit (investor owned) (26.4%, 20.6%, 19.7%, and 12.9%, respectively).
  • Hospitals with <100 or 100-399 beds were less likely than large hospitals (400+ beds) to exchange information with hospitals outside their system. Large hospitals also were more likely than medium and small hospitals (37.5%, 35.5%, and 26.4%, respectively) to have electronic exchange with ambulatory providers outside their system.
  • In 2010, nonprofit hospitals were most likely to have electronic exchange with ambulatory providers outside their system, followed by non-Federal, for profit, and Federal.

Also, in the NHDR:

  • In 2010, hospitals in the West were the most likely to exchange information with ambulatory providers outside their system, followed by hospitals in the Northeast, South, and Midwest.

New! Children With Special Health Care Needs

Addressing questions on access to and quality of care for children with chronic conditions is difficult due to the low prevalence of most conditions in children. A standard definition of CSHCN was developed in 1995. This definition was subsequently used to develop the CSHCN Screener Questionnaire and was included in the National Survey of Children With Special Health Care Needs, among other surveys.

According to the Medical Expenditure Panel Survey, in 2004, approximately 13.8 million children, or 20% of the population ages 0-17, were identified as having a special health care need (i.e., a specific chronic condition with a functional limitation or other consequence). Among the most highly prevalent chronic conditions of childhood in 2005 were asthma (13% of children under age 18), upper respiratory allergies (12% of children under 18), learning disabilities (7% of children ages 3-17), and attention-deficit/hyperactivity disorder (7% of children ages 3-17). Other conditions that may affect CSHCN include depression, spina bifida, hemophilia, HIV infection, cystic fibrosis, and metabolic disorders.

Having greater health care needs makes CSHCN susceptible to cost, quality, and access weaknesses in the health care system. Because they need more medical care, CSHCN have higher medical expenses, on average, than other children. For more than one in five CSHCN, costs of care caused financial problems for their families.

In addition to financial burdens, families of CSHCN spend considerable time caring for them. An estimated 9.7% of CSHCN had families who spent 11 or more hours per week providing or coordinating care in 2005-2006 (MCHB, 2007). Studies have documented that children with chronic conditions in poor families and racial and ethnic minority groups may experience lower quality care. Children with chronic conditions are reported by their parents to be less likely than other children to receive the full range of needed health services. Among CSHCN, minorities are more likely than White children to be without health insurance coverage or a usual source of care.

  Figure 6.5. Effective care coordination among children with special health care needs, overall and by age and insurance status, 2009-2010

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Source: Health Resources and Services Administration, Maternal and Child Health Bureau; Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Children With Special Health Care Needs (CSHCN), 2009-2010.
Denominator : CSHCN who were reported to use more than one service during the survey period.

  • In 2009-2010, the percentage of CSHCN who had effective care coordination was higher for children ages 0-5 than for children ages 6-11 and 12-17 (58.8% compared with 54.9% and 55.5%, respectively; Figure 6.5).
  • Also in 2009-2010, the percentage of CSHCN who had effective care coordination was higher for children with private insurance compared with children with only public insurance, private and public insurance, and no insurance (60.8% compared with 51.4%, 53.1%, and 37.7%, respectively).

  Figure 6.6. Children with special health care needs with a medical home, overall and by age and insurance, 2009-2010

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Source: Health Resources and Services Administration, Maternal and Child Health Bureau; Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Children With Special Health Care Needs (CSHCN), 2009-2010.
Denominator : Civilian noninstitutionalized population ages 0-17 with special health care needs.

  • In 2009-2010, the percentage of CSHCN needs who had a medical home was higher for children ages 0-5 compared with children ages 6-11 and 12-17 (44.2% compared with 42.1% and 43.1%, respectively; Figure 6.6).
  • Also in 2009-2010, the percentage of CSHCN who had a medical home was higher for children with private insurance compared with children with only public insurance, private and public insurance, and no insurance (51.2% compared with 34%, 35.3%, and 24.2%, respectively).

References

Bodenheimer T. Coordinating care—a perilous journey through the health care system. New Engl J Med 2008;358(10):1064-71.

Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006;166(17):1822-8.

Maternal and Child Health Bureau (HRSA) and National Center for Health Statistics (CDC). National Survey of Children With Special Health Care Needs, 2005-2006. Rockville, MD: Health Resources and Services Administration and Centers for Disease Control and Prevention; 2007.

Powell-Davies G, Williams AM, Larsen K, et al. Coordinating primary health care: an analysis of the outcomes of a systematic review. Med J Aust 2008;188(8 Suppl):S65-68.

Shojania K, McDonald K, Wachter R, et al. Closing the quality gap: a critical analysis of quality improvement strategies—Volume 7: Care coordination. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Available at: http://www.ahrq.gov/research/findings/evidence-based-reports/asthmgaptp.html. Accessed March 14, 2013.

Whittington J, Cohen H. OSF Healthcare's journey in patient safety. Qual Manag Health Care 2004;13(1):53-59.


i. For more information, go to http://hab.hrsa.gov/abouthab/special/underservedcommunities.html.
ii. Available at: http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm.
iii. The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, New Hampshire, New Jersey, and Utah.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Quality Report: Chapter 6. Care Coordination. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr12/chap6.html