Which systemic care coordination strategies should be maximized to improve clinical

integration in hospitals and integrated healthcare delivery systems?

Soraya GheblehMay 29, 2013

The Dartmouth Institute for Health Policy and Clinical Practice

Background Trends in Current Healthcare Environment Clinical Integration Systemic Care Coordination Strategies

Conceptual Framework Methods and Search Strategy

Overview Inclusion Criteria Search Results Limitations

Results Characteristics of Included Studies Summary of Results Methodological Quality

Synthesis Completeness and Applicability of the Evidence Common Themes of Care Coordination Interventions

Recommendations Implications for Institutions Interested in Clinical Integration Framework to Improve Clinical Integration using Systemic Care Coordination Strategies Conclusions Future Research

Executive summary

Trend #1: Fragmented Delivery of Care

Trend #2: Healthcare Reform

Trend #3: Increased Consolidation Activity

Three Current trends Shaping the healthcare environment

AIM: To bring providers together to manage care in a more standardized, coordinated, effective, and efficient manner, leading to improvement in quality for patients.

PRIMARY CHARACTERISTICS AS DEFINED BY THE FEDERAL TRADE COMMISSION:(1)Ability to achieve significant clinical and economic efficiencies(2)Broad physician representation and physician intervention(3)A well-developed care management program that uses evidence-based guidelines(4)A data management system that enables extensive data collection, information sharing, and utilization review

clinical integration and quality

Care Coordination is defined as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.”1

Mechanism by which clinical integration can be improved through comprehensive interventions

Systemic care coordination strategies involve collaboration between multiple disciplines within an institution or between institutions

Care coordination

1 Source: Care Coordination, Quality Improvement: Structured Abstract. June 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/caregaptp.html

Conceptual framework

A systematic review of the available literature in the Business and Medical databases was performed in April 2013. The specific databases searched were MEDLINE via PubMed, ABI/Inform, Business Source Complete, and CINAHL.

A search strategy and specific inclusion criteria were established a priori.

All databases were searched from 1990-2013. Search terms utilized were “integration,” “care coordination,” “hospitals,” and “healthcare systems.” The Boolean terms “AND” and “OR” were used to find intersection between these terms

overview of methods

Studies were included that met the following criteria: (1) study designs consisting of randomized controlled trials, cohort studies, case-control studies, before-after studies, pseudo-experimental or non-randomized trials, cross-sectional studies, and case studies (2) intervention must fall under one of the five broad approaches of care coordination as identified by the Agency for Healthcare Research and Quality (3) intervention must aim to further integrate setting where intervention is being implemented(4) intervention must be limited to hospital-wide settings, integrated health systems or a hospital clinic setting that involves multi-disciplinary collaboration(5) intervention must be a systemic intervention (6) studies were limited to 1990 to April 2013.

Inclusion criterion

results of search

77 studies were identified from ABI/Inform, 185 studies from MEDLINE via Pubmed, 193 from CINAHL, and 136 from Business Source Complete. A total of 592 records were identified through a database search and 94 duplicates were removed. A remaining 498 studies were then screened by title and abstract. 441 studies were excluded and 57 remaining full text articles were then screened for eligibility. Of the 57 full text articles that were screened, 13 met the inclusion criteria.

Numerous definitions for both clinical integration and care coordination exist in the literature

Lack of consensus on appropriate measures of clinical integration

Deficit of high-quality, empirical studies measuring the effects of care coordination on clinical integration

Review was performed by only one individual, leaving room for potential error

limitations of search Strategy

Interventions all met one of the five broad categories of care coordination interventions as defined by the Agency for Healthcare Research and QualityOutcomes of all studies included at least one of the four components of clinical integration as defined by the Federal Trade Commission Five of the thirteen studies examined interventions implemented across an integrated delivery systemSix studied single institution interventions Two studies compared multiple settings

Characteristics of included studies

characteristics of included studies

summary of results

All studies gave insight into the design and implementation of care coordination interventions

Varied reporting of quantitative results across studies

Metrics reported included length of stay, hospital utilizations, patient satisfaction, staff satisfaction, ED presentations, and cost savings

Each study gave in-depth descriptions of care coordination interventions, processes used to develop these interventions, and recommendations

A standardized abstraction tool adapted from Downs and Black was utilized to assess the methodological quality of each study

Many studies included were of low quality, had limited reporting of quantitative results, and lacked generalizability

Difficult to find the best study design to assess the link between care coordination and clinical integration due to the limited amount of existing studies as well as the numerous metrics that can be utilized to assess this link

Reporting bias is a concern as specific positive outcomes were often reported but adverse outcomes were not

Conflict of interest was also of concern, as only four studies specifically stated that no conflict of interest was present

methodological quality

Methodological quality

High Risk

Low Risk

Unclear N/A

Eligible studies all incorporated at minimum one component of the categories of care coordination interventions and one component of the characteristics of clinical integration as an aim

Certain components of both care coordination and clinical integration were studied more than others

completeness of evidence

Unclear if the care coordination intervention was the only factor that affected clinical integration in the study setting

The appropriate study design to study the link between systemic care coordination interventions and improving clinical integration has not been determined in the literature

Institutions are consolidating to meet new demands in the healthcare environment and must become more efficient to remain competitive

Improving clinical integration through carefully implemented systemic care coordination strategies can lead to higher quality and satisfaction and has the potential to reduce costs

Care coordination strategies to improve clinical integration within a hospital can be applied systematically across a delivery system

If an institution that is part of a system implements a strategy or intervention and success is reasonably demonstrated, that institution can expand or share that strategy within the system

clinical integration within and between institutions

Despite variations in quality and generalizability of included studies, the synthesis revealed common components of interventions regardless of study design or setting:

LeadershipCommunicationData Collection and Meaningful UtilizationFlexibilityProcess ImprovementPatient-Centered Emphasis

Common themes of care coordination interventions

Guidelines for improving clinical integration through systemic care coordination strategies

Establish leadership before implementation of intervention

Leadership can be senior management, clinical leaders, care coordinators, or teams but must be clear to the staff

Responsibilities include setting institution and organizational goals, creating an organizational structure, and ensuring appropriate management of various components of the intervention

Oversight and monitoring of the intervention is essential

Leadership

Frequent staff meetings that incorporate all levels of staff

High-touch communications strategy that emphasizes institutional goals and a culture of learning and adaptability

Cross-department communication pathways established

Sharing best practices between institutions within an integrated delivery system

Establish communication between patient and individual or team that serves as single point of care

communication

Data collection is essential to any quality improvement initiative

Defined metrics should be established and data collection should begin prior to any intervention

Data should be benchmarked with institutional and national data

Real-time data collection allows for adaptive learning and necessary adjustments to be implemented

Effective utilization of healthcare information technology to ensure data is being collected efficiently

data collection & meaningful utilization

Flexibility is necessary in two contexts: (1) Institutional Flexibility (2) Point of Contact for Patient

flexibility

Institutions require adaptability with implementation of interventions, as no two settings are entirely homogeneous

The point of contact for the patient must have the ability to span departments to ensure proper management of patient care

Beneficial for care coordination staff or intervention leadership to give an outside perspective on pathways and processes occurring in the institution

process improvement

Adaptive learning to adjust, enhance, and improve implemented interventions

Incorporation of data collection, staff and patient feedback, evidence from the literature, and existing clinical pathways to strive for improved outcomes and efficiency

Process improvement measures should be performed as problem areas are defined and should be adapted as data is collected

patient-centered emphasis

Goal of any intervention is ultimately to improve outcomes and quality for patients

Comprehensive care management plans should be designed for high-risk and high-utilizing patients

Patient feedback is informative for improvement and can provide insight beyond the perspective of providers

Patient and caregiver satisfaction should be kept in mind with any intervention designed to improve patient care and overall experience

Patient care pathway is integral to any systemic care coordination intervention

More high quality studies with empirical data should be performed

Studies should involve comprehensive systemic care coordination interventions that encompass all of the broad categories as defined by the AHRQ

Outcomes should be identified and defined before the intervention is implemented and an adequate time period should be established for follow-up

A standardized, validated, systematic, evidence-based tool needs to be developed to effectively evaluate integration in order to compare different hospitals and integrated delivery systems

Future research

Relationship between care coordination and clinical integration is important in the context of healthcare reform and increased consolidation

These different components can be used to develop a comprehensive, systemic, care coordination plan that has the potential to improve clinical integration within an institution and between institutions

conclusions

There is no identical, repeatable care coordination plan guaranteed to work in every institution

Further research and higher-level study should be performed as coordinating care at a systemic level shows great promise to improve the quality and experience of healthcare delivery