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Coordination of Care: The Patient’s Journey Improving Community Health Care Systems. Annette Kritzler, RHIT, CPHQ Minnesota Rural Health Conference July 18, 2006. Objectives. Define “coordination of care” and its significance to quality improvement

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coordination of care the patient s journey improving community health care systems

Coordination of Care: The Patient’s JourneyImproving CommunityHealth Care Systems

Annette Kritzler, RHIT, CPHQ

Minnesota Rural Health Conference

July 18, 2006

  • Define “coordination of care” and its significance to quality improvement
  • Describe barriers and frustrations for health care providers and patients/families in transitioning and navigating care among health care settings
  • Understand the significance of communication in building patient-centered communities of care
  • Summarize learnings of a rural health coordination of care mini-collaborative

Dr. Eric Coleman

University of Colorado


Dr. Eric Coleman

University of Colorado


Coordinating the Patient’s Journey

Emergency Care


Access to care

Person in need







Care Coordination




Social Work


Physical Therapy



Karen Zander, The Center for Case Management

institute of medicine s six aims
Institute of Medicine’s Six Aims

QIOs support the Institute of Medicine’s six aims that challenge us to provide health care that is:

+ Safe

+ Timely

+ Effective

+ Efficient

+ Equitable

+ Patient Centered


Coordination of Care?

what is coordination of care
What is Coordination of Care?
  • Known by many different names…
    • Throughput
    • Discharge planning
    • Care management
    • Transitioning care
    • Improving access to care
    • Continuity of care
    • Optimizing patient flow
    • Process and system redesign:

otherwise known as

quality improvement

why focus on coordination of care
Why Focus on Coordination of Care?
  • Increasingly complex systems and processes of care
  • Growing elderly population with multiple chronic illnesses
  • Pressure from regulators and payers
  • Pay for reporting has placed an emphasis on improving quality and patient safety
  • Coordination of care is vital to achieving the IOM aims
  • Coordination of care equates to the patient’s experience of care
  • It’s the right thing to do!
why is coordination of care a problem
Why is Coordination of Care a Problem?
  • Older adults with complex care needs frequently require care in multiple settings
  • Health care professionals in these settings often function independent from one another
  • As a result, care is fragmented
  • Patient safety and quality are compromised
  • Caregivers become frustrated
  • Patients are left to fend for themselves
challenges at multiple levels
Challenges at Multiple Levels
  • Patient
  • Health care provider
  • Health care organization
  • Health information technology
  • Performance measurement



Patient Centered Care?


Skilled Nursing Facility

Emergency Services

Ambulatory Care Clinic


Rehabilitation Facility


  • Unprepared and uncertain about their role
  • Institutions foster dependency and complacency
  • This changes abruptly on transfer/discharge when expected to assume major role in self-care
  • Rising prevalence of cognitive impairment intensifies this challenge
health care provider
Health Care Provider
  • Rare for one clinician to orchestrate care across multiple settings
  • Rise of hospitalists and SNFists
  • Many health care providers have never practiced in settings to which they transfer patients

Health Care Organizations




Dr. Eric Coleman

University of Colorado

health information technology
Health Information Technology
  • Health information technology infrequently extends from emergency transport to the hospital or clinic into post-acute care settings
  • Electronic health records do not have interconnectivity
  • Vendors do not have a product that meets both inpatient and outpatient needs
  • Settings do not have a shared and standard language
performance measurement
Performance Measurement
  • Lack of measurement for coordination of care is a significant barrier to quality improvement
  • Proxy or outcome measures do not adequately capture the process of transitioning care
  • Each setting has a different quality improvement infrastructure
  • Monitoring care and the transition across settings is a challenge!
minnesota s work with coordination of care
Minnesota’s Work with Coordination of Care
  • Focus on rural Minnesota communities
    • 2003-2005 initiative
why focus on rural
Why Focus on Rural?
  • Need first arose in a rural community
  • Rural health care community was conducive to the proposed initiative:
    • A large rural provider and senior population
    • Strong health care networks and systems
    • A collaborative Rural Flex Program office
  • Positive past experience with rural collaboratives
why focus on rural cont
Why Focus on Rural? (cont.)
  • Rural Minnesota has 30% of state’s population
    • 40% of those are 65+
  • Minnesota has one of the highest per capita rates of hospitals, nursing homes, and home health agencies, largely because of small rural providers
  • Two-thirds of Minnesota hospitals are Critical Access Hospitals
    • Associated LTC, clinic, home care
coordination of care mini collaborative
Coordination of Care “Mini-collaborative”
  • Adapted the nationally known IHI Breakthrough Series collaborative model to focus on coordination of care in rural Minnesota communities
    • Stratis Health worked cooperatively with partner organizations to develop and implement the collaborative regionally, providing subject matter experts, QI education and consultation, venues for sharing, and facility support
coordination of care mini collaborative cont
Coordination of Care “Mini-collaborative” (cont.)
  • Stratis Health partnered with:
    • MDH’s Office of Rural Health and Primary Care
    • Minnesota Association of Area Agencies on Aging
      • Hospitals
      • Nursing homes
      • Home care
      • Public health
      • Parish nurses
      • Other health care providers
coordination of care mini collaborative cont1
Coordination of Care “Mini-Collaborative” (cont.)
  • Presented in sixregions of the state,aligning with therural AAA geographical areas
coordination of care mini collaborative cont2
Coordination of Care “Mini-Collaborative” (cont.)
  • Five month duration in each region
  • Two learning sessions
    • Discharge planning models
    • Case management overview
    • Health literacy
    • Generational communication
    • Community sharing
      • Unique barriers
      • Community models of excellence
      • Networking and learning from each other
      • AAA resources
coordination of care mini collaborative cont3
Coordination of Care “Mini-Collaborative” (cont.)
  • Three expert speaker conference calls
    • HIPAA, UR, transitional care models

Discharge Planning Quality Resources Kit:

Data collection

Policies and procedures

Assessment/reassessment tools

Staff education, patient/family education


resources cont
Resources (cont.)

  • Care Transitions Intervention
    • Manual
    • Video clips/order DVD
    • Tools for patients and caregivers
  • Medication Discrepancy Tool
  • Care Transitions Measures
care transitions measures
Care Transitions Measures
  • When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
  • When I left the hospital, I clearly understood the purpose for taking each of my medications.
  • The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.

key issues identified from collaborative work
Key Issues Identified From Collaborative Work
  • Communication
    • Lack of information most commonly cited issue
    • Lack of communication among settings, as well as with patient and family
  • Patient control
    • Patient and family preference on care transitioning not taken into consideration
    • Patient confusion about insurance coverage and reimbursement
key issues identified from collaborative work cont
Key Issues Identified from Collaborative Work (cont.)
  • Health care services
    • Nursing homes don’t admit residents on the weekend
    • Lack of available psychiatric services
  • Measurement
    • Process measures across settings?
qio lessons learned
QIO Lessons Learned
  • Partners
    • Re-alignment of AAA regions
    • Regional AAA engagement varied
  • Planning
    • Content evolved over time
    • All regions are not the same (flexibility)
qio lessons learned cont
QIO Lessons Learned (cont.)
  • Measurement
    • Accustomed to data driven initiatives
    • “Soft” science
  • Communicating with participants
    • List of participants was enormous
    • Listserve was not effective
success stories
Success Stories
  • Qualitative vs. Quantitative in nature
  • Success across the state:
    • Within organizations
    • Between settings of care
    • Community wide
    • Regionally
    • Statewide
take away lesson the power of hearing the patient
Take-Away Lesson:The Power of Hearing the Patient

Listen to Helen’s story . . .

  • Do you hear her concerns?
  • What is she telling you about coordination of care?
  • How could her transition have been improved?
  • What barriers exist in your organization that prevent you from hearing your patients?
  • How do you learn to hear our patients?
vignette listening to helen s
Vignette: Listening to Helen(s)
  • If you are interested in using these stories for education at your facility, please send an email to:
the work continues
The Work Continues
  • Quarterly coordination of care conference calls/WebEx
    • Highlight best practices and new approaches
    • Share national speakers
    • Maintain the focus
  • Coordination care section of e-newsletter
  • A Patient’s Guide to Leaving the Hospital
a patient centered approach to care
A Patient Centered Approach to Care
  • Institute of Medicine’s 2001 report: Crossing the Quality Chasm: A New Health System for the 21st Century
    • Patient centeredness
  • “We are guests in our patients’ livesinstead of hosts in our health care organizations.”
  • - Donald M. Berwick, President and CEO Institute for Healthcare Improvement

Vision without action is merely a dream.Action without vision just passes the time.Vision with action can change the world

  • Joel Barker, The Power of Vision
contact information
Contact Information
  • Annette Kritzler, RHIT, CPHQ Hospital Project Manager

Stratis Health



Stratis Health is a non-profit

independent quality improvement organization

that collaborates with providers and consumers

to improve health care.

This material was prepared by Stratis Health under a contract with the Centers for Medicare & Medicaid Services (CMS),

an agency of the U.S. Department of health and Human Services. The contents presented do not necessarily reflect CMS policy.