Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. 1.3. Care Coordination During Care Transitions and Shared Care

10/29/2013

Care coordination is the deliberate organization of patient care activities to facilitate the appropriate delivery of health care services. It involves activities to promote, improve, and assess integration and consistency of care across primary care physicians, specialists, acute and LTSS/LTPAC services, patients and care providers, including methods to manage care throughout an episode and during transitions.7 Examples of care coordination activities include supporting individuals during transitions (e.g., the movement of a patient from one setting of care to another), and arranging for the timely delivery of needed services. Transitions coordination may involve discharge planning, setting up post-discharge followup appointments with primary care and specialty providers, coordinating medication and other therapy services post-discharge, in addition to arranging for other supports such as medical equipment that may be needed in the home. Care coordination is also important for assessing patient needs and goals, creating a plan of care (POC), monitoring, following up, responding to changes in the patient, and linking patients to community resources. These coordination activities require sharing of patient health and other information to ensure continuity of care and services needed for the recovery, rehabilitation, and health maintenance of the patient.

The Agency for Healthcare Research and Quality (AHRQ), in its Care Coordination Measures Atlas, proposed a definition and framework for integrated care. Integrated care is viewed as multidimensional construct rather than one-dimensional organizational activities, and is defined as "patient care that is coordinated across professionals, facilities, and support systems; continuous over time and between visits; tailored to the patient's needs and preferences, and based on shared responsibility between the patient and caregivers for optimizing health."8 Relevant constructs from the AHRQ framework that informed this study are the need to coordinate care across teams, between teams, and with community resources; shared responsibility with patients and caregivers; and continuous familiarity with the patient over time.9

Shared care and decision-making10 can be facilitated by care coordination, communication, and HIE among all care organizations providing care and support to the patient. Shared care, also referred to as "shared management of care" refers to patient and health care providers (e.g., physicians and LTPAC/LTSS providers) working together as a team, which may also include family members, friends, or lay caregivers designated by the patient, guided by the preferences and expectations of the patient. Shared decision-making is a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences.11

Poorly coordinated care transitions, especially those from hospitals, and other care hand-offs, are associated with hospital readmissions, emergency department (ED) visits, medication errors, adverse drug events (ADEs), and other negative outcomes, which greatly affect the cost of care.12131415161718 The high rates of hospital readmissions of Medicare beneficiaries within 30 days of discharge in general (20%)19and for those beneficiaries discharged to SNFs (almost 25%) have been widely reported.13192021 Approximately half of all hospital-related medication errors, and 20% of all ADEs, have been attributed to poor communication during transitions of care, and these can result in hospital readmissions.22 Communication breakdowns are the root cause of approximately 80% of sentinel eventsb reported to the Joint Commission.23 When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans,1318 and prevent medical errors.24 Many care transition models, programs, initiatives (see Appendix A), and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers.142526


  1. LTPAC Health IT Collaborative. A roadmap for health IT in long term and post-acute care, 2010-2012. Available athttp://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047579.pdf. Accessed July 25, 2013.

  2. McDonald K, Schultz E, Albin L, et al. Care coordination measures atlas version 3. Rockville, MD: Prepared by Stanford University under Subcontract to Battelle on Contract No. 290-04-0020 for the AHRQ; 2010. AHRQ Publication No. 11-0023-EF.

  3. Singer SJ, Burgers J, Friedberg M, et al. Defining and measuring integrated patient care: Promoting the next frontier in health care delivery. Medical Care Research and Review; 2011; 68(1):112-127.

  4. Office of the National Coordinator for Health Information Technology policy framework RFTOP. Solicitation No 12-233-SOL-00615; 2012.

  5. Informed Medical Decisions Foundation. What is shared decision making? Available at http://informedmedicaldecisions.org/what-is-shared-decision-making/. Accessed January 12, 2013.

  6. Gruneir A, Bronskill S, Bell C, et al. Recent health care transitions and emergency department use by chronic long-term care residents: A population-based cohort study. J Am Med Dir Assoc; 2012; 13(3): 202-206.

  7. Mor V, Intrator O, Feng Z, et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff; 2010; 29(1): 57-64.

  8. Naylor MD, Kurtzman ET, Pauly MV. Transitions of elders between long-term care and hospitals. Pol. Polit. Nurs. Pract.; 2009; 10(3): 187-194.

  9. Boling  PA. Care transitions and home health care. Clin in Geriatr Med; 2009; 25(1): 135-148. 

  10. Bayley KB, Savitz LA, Rodriguez G, et al. Barriers associated with medication information handoffs. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation. Rockville, MD; 2005.

  11. Chhabra PT, Rattinger GB, Dutcher SK, et al. Medication reconciliation during the transition to and from long-term care settings: A systemic review. Res Soc Admin Pharm; 2012; 8(1): 60.

  12. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med; 2003; 138(3): 161-167.

  13. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med; 2009; 360(14): 1418-1428.

  14. Thorpe KE. The Medicare advantage experience: Lessons for reform to original Medicare. Atlanta, GA: Emory University Rollins School of Public Health; 2012.

  15. Clancy CM. Commentary: Reducing hospital readmissions: Aligning financial and quality incentives. Am J Med Qual; 2012; 27(5): 441-443.

  16. Barnsteiner JH. Medication reconciliation: Transfer of medication information across settings-keeping it free from error. J Infus Nurs; 2005; 28(2 Suppl): 31-36.

  17. Sentinel events statistics for 2011. Jt Comm Perspect; 2012; 32(5): 5.

  18. Office of the National Coordinator for Health Information Technology. Getting to impact: Harnessing health information technology to support improved care coordination. In State HIE Bright Spots Synthesis: Care Coordination Part 1. Washington, DC: ONC; 2012. Available at http://statehieresources.org/wp-content/uploads/2013/01/Bright-Spots-Synthesis_Care-Coordination-Part-1_Final_010913.pdf.

  19. Murray LM, Laditka SB. Care Transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. J Am Med Dir Assoc; 2010; 11(4): 231-238.

  20. LaMantia MA, Scheunemann LP, Viera AJ, et al. Interventions to improve transitional care between nursing homes and hospitals: A systemic review. J Am Geriatr Soc; 2010; 58(4): 777-782.

b. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

View full report

Preview
Download

"HIEengage.pdf" (pdf, 976.86Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageA.pdf" (pdf, 122.65Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageB.pdf" (pdf, 132.47Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageC.pdf" (pdf, 62.72Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageD.pdf" (pdf, 64.52Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageE.pdf" (pdf, 71.74Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageF.pdf" (pdf, 67.17Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageG.pdf" (pdf, 128.62Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageH.pdf" (pdf, 1.02Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageI.pdf" (pdf, 264.75Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageJ.pdf" (pdf, 663.47Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageK.pdf" (pdf, 126.77Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageL.pdf" (pdf, 141.17Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"HIEengageM.pdf" (pdf, 83.93Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®