Review of the literature indicates that the following are the long-term outcomes that are expected to be influenced by effective and efficient care coordination (Devers 1995; Seigel1996; Van Acterberg 1996; Bennett 1997; Watson 1997; Hughes 1999; Ronder 1999; Brede, personal communication; Bulger, personal communication; Jha, personal communication):
- Improve patient experience;
- Improve family experience;
- Decrease family caregivingburden;
- Improve provider experience;6
- Maintain or improve functional status, independence and community participation;
- Maintain or improve health status; and
- Prevent secondary complications.
Some authors argue that effective care coordination should also reduce the costs of caring for people with disabilities (Master 1996). However, it is clear that savings accrue over the long-term, and may be experienced by organizations other than a given MCO, the state Medicaid agency, or even more broadly the public. For instance, long- term external outcomes may lead to less divorce. At the same time, investments both in measurement and improvement of care coordination are required up-front. It may be unrealistic to expect that care coordination will create savings in the short and mid-term, especially for the organizations that pay for the coordination. Furthermore, building in such expectations at the outset may distort both the design of care coordination efforts and their measurement (Stuart 1998).
It is important to note that the outcomes specified above are also "dependent variables" of other interventions to improve quality of care, and that if other quality dimensions are poor, even the best efforts of those coordinating care may fail to have these desired outcomes. We therefore believe that it will be important to further specify the particular aspects of patient experience, family experience, provider experience, functional status and participation that can be attributed with greater confidence to care coordination itself. For example, patient, family and provider experience with particular elements of care coordination can be specified through items in surveys (Pawlson, personal communication). We believe it will be difficult to come up with a measure of health or even functional status that will be valid, even if used with a cohort of people over time, as an indicator of MCO performance in care coordination (see our earlier Resource Guide [Sofaer 1998] for a discussion of the limitations of such outcome measures as performance indicators). While efforts may need to be made to measure and track health and functional status (perhaps for all or a significant sample of Medicaid managed care enrollees), it will be hard to attribute variations across MCOs or over time with accuracy.