Coordination of Care for Persons with Disabilities Enrolled in Medicaid Managed Care: A Conceptual Framework to Guide the Development of Measures. A. Care Coordination And Coordination

12/01/2000

The literature in organizational theory and management is a valuable source of insights in defining care coordination. The classic theorists about organizations note that in creating an organizational structure and defining roles and responsibilities, organizations must both "differentiate" (or specialize) and "integrate" (or coordinate). This distinction makes it clear that the need for coordination of any kind is inevitable, growing as it does from the need to define individual and unit roles that are specialized. We specialize in order to become both more efficient (by standardizing) and more effective (by developing special expertise). Health care as a system is highly specialized; thus it is not surprising that the need for coordination is great, and that the task of coordination is difficult.

The work of Thompson (1967) includes an especially useful discussion of coordination in an organizational context. All organizations need coordination mechanisms to handle what he terms "interdependence" between individuals and units. The same framework could also be applied to interdependence between and among entire organizations. The kind of mechanism needed to handle interdependence depends on the demands of the technology that is employed by the organization.

Thompson defines three kinds of interdependence, each requiring different kinds of mechanisms that also vary in the intensity and kind of resources and effort they require. First is "pooled" interdependence, in which the organization can only produce its goods or services by pooling the contributions of multiple individuals or units. A secondary school is organized in this way: each teacher supplies part of the curriculum for each student. The method used to coordinate in these circumstances is "standardization," in particular standardizing roles and procedures so the parts add up to the whole consistently. Second is "sequential" interdependence, in which a given individual or unit of an organization can only do its job if some other person or unit does their job correctly and in a timely manner beforehand. An example of this is a manufacturer with an assembly line. Thompson says the coordination mechanism here goes beyond standardization and into planning (including scheduling). The third type of interdependence is the most difficult to achieve, and requires the most communication and decision effort. It is "reciprocal" interdependence, and the only coordination mechanism that works in these circumstances is "mutual adjustment." In this kind of interdependence, individuals and units need certain things from each other, including both information and the appropriate performance of assigned roles, in order to produce a good or service efficiently and effectively. Notable examples of this kind of coordination are the launch of a space shuttle or a political campaign, which require timely information and adjustment.

All three kinds of interdependence are present in the delivery of health care services. We would argue, however, that reciprocal interdependence is particularly present in the delivery of services to people with disabilities. While care coordination should be designed to deal with pooled interdependence (e.g., identifying the several distinct services a person needs and making sure they get each one) and sequential interdependence (e.g., arranging and supporting transitions from hospital to home care), the most demanding tasks of care coordination involve reciprocal interdependence (e.g., making sure that changes in the home environment or the patient's condition that are identified by a visiting nurse are communicated to the primary care physician and other involved clinicians, so that adjustments can be made in prescribed medications and services).

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