Soraya Ghebleh - Clinical Integration and Care Coordination
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Transcript of Soraya Ghebleh - Clinical Integration and Care Coordination
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