Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. B.1. Care Coordination Model Functions, Care Integration Constructs and Activities

10/29/2013

TABLE B-1. Coordination of Care Model Activities by Functions and Integration Constructs

Care Coordination Model Functions, Integration Constructs, and Examples of Activities
Care Coordination
  Mechanisms/Function1  
  By Care Integration Constructs  
(information exchange participants)2
  Examples of Care Coordination  
Mechanisms and Activities
  Important to Capture  
for LTPAC HIE
  Coordinated care integration:
  • Across members of the care team within affiliated organization.
  • Between staff in an organization & other non-affiliated care providers including community services.
  • Between staff in an organization & patient/ family members.
   
Transitions in Care & Hand-offs  
  • Obtain updated core data elements from multiple sources including those listed below.
  • The flow of information, such as medical history, medication lists, test results, laboratory & radiology tests & results, & other clinical data, from 1 participant in a patient's care to another.
  • Transfer of disk with CT images from a hospital to primary care or LTPAC provider.
  • Referrals & consultations.
  • Reconcile discrepancies in medication use in order to avoid ADEs.

Specific to Transitions:

  • Review of patient's complete medication regimen at the time of ADT, including assessing use of over-the-counter medications, supplements.
  • Affiliation of exchange partners--within same integrated health care network or with non-affiliated networks.
  • Medication reconciliation tools that include/import medication data from other sources, displaying medication lists, show new, changed, & discontinued medications.
  • Community pharmacies that support LTPAC.
  • Involvement of team during hospitalization.
  • Communication between team members.
Shared Care
Assess Needs & Goals  
  • Identify problems, issues, risks & their severity.
  • Determine the patient's needs & goals for care & for coordination, including physical, emotional, & psychological health; functional status; current health & health history; self-management knowledge & behaviors; current treatment recommendations, including prescribed medications; & need for support services.
  • Record needs, preferences, values, & capabilities of the patient, family members, & other caregivers.
  • Ability to assess & exchange functional & cognitive status information.
Create a Plan of Care (POC)  
  • Establish & maintain a comprehensive POC, jointly created & managed by the patient/family & health care team, which outlines the patient's current & long-standing needs, goals, & preferences for care.
  • The plan fills gaps in coordination, establishes patient goals for care, & sets goals for the patient's providers.
  • Care plan anticipates routine needs & tracks current progress toward patient goals.
  • POC includes self-management/self-care support.
  • Educate patient about condition & self-management/self-care.
  • Relies on key information that might be relevant later in a patient's care is stored for future access such as medications, allergies, discharge instructions, procedures, & observations.
  • Patients & care coordinators may benefit from patient portals available from HIE to support self-management/self-care.
Monitor, Followup, & Respond to Change  
  • Jointly with the patient/family, assess progress toward care & coordination goals. Monitor for successes & failures in care & coordination.
  • Refine the POC as needed to accommodate new information or circumstances & to address any failures.
  • Manages/tracks tests, referrals, & outcomes.
  • Provide necessary followup care to patients.
  • Monitor patient's knowledge & services over time; intervene as needed.
  • Reassess patients & care plan periodically.
 
Link to Community Resources  
  • Provide information on the availability of community services.
  • Referrals & related activities to coordinate & arrange for services with additional community resources that may help support patients' health & wellness, & meet their care goals.
  • These might include financial resources (e.g., Medicaid, food stamps), social services, educational resources, support groups, or support programs (e.g., Meals on Wheels).

NOTES: Care coordination functions/mechanisms adapted for HIE and LTPAC/LTSS based on AHRQ Care Coordination Measures Framework;1 Care Constructs adapted from Singer Integration of Care Constructs.2

  1. 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.
  2. 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.

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